SAVE $300 TODAY On Your HOME2 Purchase! ✦ Limited-Time Offer

Questions? Call us at 1-888-959-5563

Patient Ambassadors Available Mon - Friday, 9AM - 7PM EST

For Prescribers

THANK YOU FOR BEING A REGISTERED PRESCRIBER

Submit another order for your patients to MyEyes

If you're already registered with MyEyes—use our new order system to make sending us a prescription easier.

Returning Providers

If you are a returning provider that has already referred a patient to MyEyes, please use the form below to unlock your electronic order form.

X/Twitter

This field is for validation purposes and should be left unchanged.

Submit Another Prescription Order to MyEyes

Enter the Registered Prescriber's NPI(Required)

Please enter your NPI number that you provided to MyEyes when requesting a Referral account to be setup for you.

This field is hidden when viewing the form

Email

Complete Order Referral Form Below

Use the form below to submit a valid prescription for your patient for either a rental or purchase of the iCare® HOME 2 tonometer OR the rental of the Visual Field VR Headset.

This field is hidden when viewing the form

Practice Name(Required)

This field is hidden when viewing the form

Doctors First Name(Required)

This field is hidden when viewing the form

Doctors Last Name(Required)

This field is hidden when viewing the form

Doctors Contact Information(Required)

This will be used to send you the finalized report from your patients' data if you don't have a practice email.

This field is hidden when viewing the form

Doctors Phone

This field is hidden when viewing the form

Please enter your NPI or DEA license number(Required)

This field is hidden when viewing the form

Doctor's OR Practice's Email Address(Required)

This will be used for official communication from MyEyes and where the patients HOME2 data will be sent.

This field is hidden when viewing the form

Additional Email for IOP data (optional)

About the Device

What device is this Rx for?(Required)

iCare HOME2

VisuALL Visual Field VR Headset

Please choose dispense option:(Required)

Rental

Purchase

Select a Rental Plan(Required)

Diagnose Plan: 1-4 week rental to monitor IOP spikes, fluctuations, and daily trends

Compare Plan: Two 7-day rentals to check IOP before and after treatment (e.g., SLT or medication change).

Select Rental Period(Required)

Choose a Visual Field Test Type

In the event that a patient prefers to purchase the iCare HOME2 tonometer instead of just renting the device through a MyEyes Diagnose or Compare plan, I authorize the prescription to cover either a Diagnose or Compare plan rental of the HOME2 tonometer, and/or a full purchase of the HOME2 tonometer.(Required)

Yes, I authorize this prescription to be expanded to cover a purchase if the patient desires.

Is this your first time referring a patient to MyEyes? If this is your first time referring a patient to MyEyes, we'll need to ask you a few extra questions about the prescribing doctor and gather a few details about the patient. Please use this application to refer your first patient to MyEyes: https://myeyes.northsupport.co.za/doctor-referral/register/