AVIS Glasses Provider KEDAH
If you are interested to be part of AVIS glasses provider, please complete the form below. Please don't use all capital letters when completing the form.

We will contact you with further details. A complimentary AVIS sticker will be given later to be displayed at your practice. Please contact Dr Duratul Ain 0163364293 for any enquiries.

Your name *
Must write the practice owner's full name
Your answer
Practice name *
Write full registered name eg ABC optometry
Your answer
Email *
Your answer
Practice Full Address (with postcode) *
Your answer
Phone number *
Your answer
Are you an AMO member? *
If Yes, is your membership active?
If No, do you plan to be an AMO member?
Comments/Suggestions *
Your answer
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