Client Information Request

Please complete this form press the submit button. Or you can fill out the form, print it and mail or fax to:
Mail: Coast To Coast Vision, PO Box 671309, Dallas, TX 75367
Fax: 972-991-5218

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Yes! I am interested in how the Coast to Coast Vision program can benefit my company or organization. I would like to know more about the benefit programs CTC can tailor specifically for my organization's employees' or members' needs and how CTC can create a source of revenue for my organization as well!

In addition to the Coast to Coast Vision Discount Program, I am interested in the other benefits checked below:
 

Insured Vision Care
Discount Dental Care
Discount Pharmacy
Discount Hearing Aids
Travel Assist
Discount Chiropractic Care
Discount VitaminPrograms
Counseling Services (employee assistance programs)
Cosmetic Surgery
Other, please specify 

 My organization is interested in making CTC or other benefit programs available to: 

Employer Groups
Association Members
Insureds
Other, please specify 

 Requester information: 

Name   
Position or Title Dept.  
Company Name  
What is the Nature 
of Your Business?
Address Address2
City   State ZIP 
Phone ( ) - ext.   
Fax ( ) -   

or

 

Coast to Coast Vision
14240 Proton Road • Dallas, Texas 75244
800-800-EYES • 972-701-9386

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