Create Your Account

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.

You can either upload a signed Arizona Form 5000A (or your home state's equivalent) or, if you're Arizona-based, fill it out below and we'll generate the signed PDF for you.

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)

20 items remaining — hover the button to see what's missing

Already have an account? Sign in