Email Address

We'll use this email to send you details and updates about your order and to establish an account in the EyeQue system.

Phone Number

First Name

Please provide your first name.

Last Name

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Street Address

Please provide your street address.

City

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Country

State

Postal Code

Please provide your postal code.

Referral Code

Discount Code

The fine print:

Item	Price
VERAI Lite This package includes: VERAI Device Access to VERAI platform Insight Lite Device PDCheck Device EyeQue Support Try-On Glasses^* Six Months of Tracking Service	$ {{ formatPrice(lookupPrice('VERAI_LITE'))}}
Sub Total	$ {{ formatPrice( lookupPrice('VERAI_LITE') ) }}
Shipping	$ 0.00
Due Today	$ {{ formatPrice( lookupPrice('VERAI_LITE')) }}

^*If within inventory refraction range, alternatively additional 6 months of the Tracking Service will be provided.

There was a problem charging your credit card. Please try again. If this problem persists, please contact support@eyeque.com.

Payment Information

Credit or debit card

✅ Confirmation

Thank you for your order!

Let's get you set up in EyeQue's system so that you may start using your VERAI package.

What is your gender?

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✅ Login Successful

👓 Current Prescription

How would you like to provide your current prescription information?

Please enter the values from your existing prescription below.

	SPHERE	CYLINDER	AXIS
Right Eye (OD)
Left Eye (OS)

Date	Please enter the date the prescription was issued.
Prescriber	Please enter the name of the doctor or clinic that issued the prescription.
PD

Please click the button below to upload a file from your computer. Once you have selected the file, click "Submit" to upload your prescription. You may upload a PDF, JPG, GIF or JPG file.

✅ Confirmation

Thank you for your order!

✅ Login Successful

👓 Current Prescription

How would you like to provide your current prescription information?

Please enter the values from your existing prescription below.

Please click the button below to upload a file from your computer. Once you have selected the file, click "Submit" to upload your prescription. You may upload a PDF, JPG, GIF or JPG file.

Vision and Medical History

I have:

I am currently experiencing:

I have a history of:

Tobacco Use

Alcohol Use

Daily Medications

Allergies

Primary Provider Contact

Item

Price

✅ Confirmation

Thank you for your order!

✅ Login Successful

👓 Current Prescription

How would you like to provide your current prescription information?

Please enter the values from your existing prescription below.

Please click the button below to upload a file from your computer. Once you have selected the file, click "Submit" to upload your prescription. You may upload a PDF, JPG, GIF or JPG file.

Vision and Medical History

I have:

I am currently experiencing:

I have a history of:

Tobacco Use

Alcohol Use

Daily Medications

Allergies

Primary Provider Contact