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First name:​

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Sir name:​

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Ophthalmologist:​

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Title:​

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Optometrist:​

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Name of clinic:​

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I hereby declare that I'm an ophthalmologist/ optometrist.

I understand that in case I fail to prove of being a professional eye-care specialist upon company's request,

The company may terminate my provider's registration, and the purchased software licenses may be blocked for access without a refund

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