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Account Credentials

Email Address *

Password *

Minimum 8 characters

Confirm Password *

Business Information

Enter your business information

Practice / Business Name *

Practice Type *

Monthly Lens Volume *

Helps us prioritize high-value leads for follow-up.

Primary Contact – First Name *

Primary Contact – Last Name *

Primary Contact – Title *

Primary Contact – Direct Email *

Billing Contact Email (if different)

Current Lab (optional)

Practitioner NPI Number

US healthcare provider identifier (can be verified via NPI Registry).

Phone *

Physical Practice Address – Street *

City *

State *

ZIP *

Professional License (optional) – Photo or PDF of state optometry license

Drag and drop a PDF file here, or

PDF only, max 5MB

State Tax & Legal Compliance

Arizona Department of Revenue requirements for wholesale.

Resale certificate required

To comply with Arizona Department of Revenue requirements for wholesale transactions, we must have a valid Resale Certificate on file before your first order can be processed.

Instructions: Download Arizona Form 5000A. Fill in your business info and Tax ID (Arizona TPT or your home state's ID). Sign and upload it below.

Please ensure you are using Form 5000A (Resale Certificate). We cannot accept Form 5000 or a simple copy of your TPT License as a substitute for this signed certificate per Arizona Department of Revenue requirements.

Arizona TPT Number / Out-of-State Resale ID *

Business EIN *

Required for credit records and KYC.

Upload signed Arizona Form 5000A (or your state's equivalent) Resale Certificate (PDF) **

Drag and drop a PDF file here, or

PDF only, max 5MB

Agreements

I agree to the Panomatiq B2B Terms of Sale, including Net 15 terms and the Manufacturer Warranty Pass-Through.I authorize Panomatiq LLC to act as a Business Associate for the processing of PHI (Patient Names/Prescriptions) under a HIPAA Business Associate Agreement (BAA).

How did you hear about us? (Optional)

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