AVIS Glasses Provider P. PINANG
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.

Thanks.
Your name *
Write the practice owner's full name. Must be a registered optometrist.
Your answer
Practice name *
Write full registered name eg ABC optometry
Your answer
Practice Full Address *
Your answer
Postcode *
Your answer
Email *
Your answer
Phone number *
Your answer
Are you an AMO member? *
If Yes, is your membership active?
If No, are you interested to be an AMO member?
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