Please fill the required information

OK

Please do not close or Refresh

Practice Information
Office Information
Prescriber Information
Alert Communication

Practice Information

Practice Name ^*

Practice Website

How Did You Hear About Us ? ^*

Primary Practice Contact

Your practice’s main point of contact for Notal Vision

First Name ^*

Last Name ^*

Email ^*

Phone ^*

Please enter Numbers Only

Is the practice contact also a prescriber?

What EMR/EHR system does your practice use? ^*

^* Indicates a required field

Office Information

Address ^*

City ^*

State ^*

Zip ^*

Please enter Numbers Only

Country ^*

Phone ^*

Please enter Numbers Only

Fax

Please enter Numbers Only

Primary Office Contact

Your office’s main point of contact for Notal Vision

Is the Office Contact the same as the Practice's Primary Contact?

First Name ^*

Last Name ^*

Email ^*

Phone ^*

Please enter Numbers Only

Is the office contact also a prescriber?

Patient Alert Recipients

Patient Alert notifications inform you of a statistically significant change in a patient’s test. It is also your office’s prompt to contact the patient for a follow up visit and to log into the ForeseeHome Prescriber Portal or App to review the patient’s report. A monthly summary report for each patient will also be sent to each email address listed. Please list up to three recipients below (at least one is required).

Check here if the Office Contact should receive Patient Alert Notifications.

First Name ^*

Last Name ^*

Email ^*

Phone ^*

Please enter Numbers Only

Please add the Recipient Div

Please add the Recipient Div

Add Additional Alert Recipients

Add Additional Offices

Check here to allow Notal Vision to share your participation as a prescribing practice through various online channels, including the ForeseeHome patient website “Find a Doctor” application.

Check this box to agree to receive product and disease-state information from Notal Vision and its affiliates, service providers, and co-promotion partners

^* Indicates a required field

FORESEEHOME PRESCRIBERS

List all eye care professionals authorized to prescribe ForeseeHome.

Prescriber Details

Prescriber Details

Prescriber Details

First Name ^*

Last Name ^*

NPI ^*

Please enter Numbers Only

Speciality ^*

Phone ^*

Please enter Numbers Only

Office Location ^*

Check here for this prescriber to receive Patient Alert Notifications.

Email ^*

Add Additional Prescribers

^* Indicates a required field

Patient Alert Communication

Please select which of the following additional patient alert emails you would like to receive:

New prescription received

Patient onboarding complete

Notal Vision unable to reach patient

Patient declined onboarding process

Patient withdrew

Enter Correct Captcha Code

Enter the numbers/letters in the blue box ^*

refresh

^* Indicates a required field

Web Privacy Policy Notice of Privacy Policy Patents NotalVision.com Contact Us References Order Form

FDA Indication for Use

The ForeseeHome is intended for use in the detection and characterization of central and paracentral metamorphopsia (visual distortion) in patients with age-related macular degeneration, as an aid in monitoring progression of disease factors causing metamorphopsia including but not limited to choroidal neovascularization (CNV). It is intended to be used at home for patients with stable fixation.

The ForeseeHome AMD Monitoring Program is only available by physician order and is intended to be used as an addition to regular eye exams.

The technical component of the ForeseeHome AMD Monitoring Program is covered by Medicare, subject to its coverage requirements for the test, to assess patients with dry AMD who are at risk of developing wet AMD. Please refer to your local Medicare Administrative Contractor (MAC) for which the ordering physician resides concerning coverage availability for the physician professional services component of the test.