New Practice CAPP Account Activation

Welcome! Next step is to set up your CAPP account. To help us best serve you, please complete this form. Once you submit it, our engineers can set up your account.

If you have any questions please email Becky Smith at bsmith@practicedomination.com

Your Full Name *

Your Email *

Marketing Director's Name *

Marketing Director's Email *

Sales/Refractive Coordinator First Name *

Sales/Refractive Coordinator Last Name *

Sales/Refractive Coordinator Email *

Practice Name *

Practice Email (Should be different from Sales/Refractive Coordinator Email) *

Street *

City *

State *

Postal code *

Country *

Website *

Practice Phone Number *

Organization Logo Url

If you would like a free customized marketing campaign and blueprint, enter your name and email address below to get started.