Practitioner Registration Form Please complete the following information to register your account for the ODG Net Results Program. If you do not have an ODG account number please fill out a "New Account Application". * Denotes required fields * ODG Account Number: Are you a member of a buying group ? Yes No If yes, please select your group: Select Your Buying Group ADO BUYING GROUP Block Buying Group Buyer's Edge Heartland Optical Buying Group HMI Buying Group THE ALLIANCE Villavecchia Buying Group Vision West Buying Group Inc. VVS Buying Group Western Professional, LLC * Account Name: * Address 1: Address 2: Address 3: * City: * State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming * Zip: * Phone: Fax: * A valid email address is required for the Net Results program. This address will be used to keep you informed of order status and processing as well as updates to ODG products, pricing and policies. If you do not have an email address for your practice you can obtain a free email account from excite.com, hotmail.com or yahoo.com * Email: * Choose a Password: * Re-type password:

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