iSLA™ Customization Form

Please complete this form to help us customize your iSLA™ device to ensure optimal compatibility with your mobile device and slit lamp.

First Name

Last Name

Practice Name

Email Address

Name as it appears on Facebook (used to send you an invitation to the iSLA™ Eye Docs group)

Do you plan to keep your iSLA™ attached to your slit lamp at all times? Or do you plan on only attaching it when you would like to take a photo?

Will keep attached at all times

Will only attach to slit lamp when taking a photo

Shipping information

Address Line 1:

Address Line 2:

City

State/Province:

Zip:

Slit Lamp Information