Request an online account

Thank you for your interest in Keeler products.

This form must be completed in its ENTIRETY to create an account with Keeler USA.

Please note that Keeler USA only services the EYE CARE industry. We cannot supply you if your business is not within this sector.

Billing Address:

Your name or facility name*

Legal business name

Billing address:

Suite/Building number*

Street address

City

State

Zip

Phone:

Email address*:

Payment terms requested:

Net 30 Credit Card

Please select

Tax exempt:

Yes No

Please select

Tax exempt number

A hardcopy of your exemption form will be requested and you must provide this before we can verify your account application.

Shipping address (if different to billing):

Your name or facility name*

Name of practice

Residential address?

Please note that we do not ship to residential addresses. Your shipping address must be to an authorized medical facility.

Address:

Suite/Building number*

Street address

City

State

Zip

Customer shipping account

if requested

Accounts Payable contact:

Name:

Last

First

Email address (AP enquiries)*:

Email address (e-invoice submissions)*:

Phone:

General information:

Please answer all questions

Physician state license number:

Students are exempt

Physician specialty:

Anticipated number of patients seen monthly:

Anticipated monthly value:

$500 / LESS $1K-$10K $10K-$20K $20K /UP

YES

Yes! Please enroll me in the Keeler rewards club program to earn reward points with every clinical purchase, which can be redeemed against brand new ophthalmic equipment. I understand you will contact me occasionally with reward account statements or program updates and I can unsubscribe at any time.

YES

Yes! Please sign me up to receive occasional Keeler newsletters so that I am the first to hear about promotions, business news and new products. I understand my data will never be shared with anyone else and I can unsubscribe at any time.