Issue Proprietary Brand Product Voucher
This page is intended for VSP Internal Use Only. ~
Account Information
Please fill out the following fields, select the voucher type, and click submit. An email that includes a unique voucher code and redemption instructions will be sent to the contact provided.
Rep Territory Code
Event Code (if applicable)
Recipient Name
Recipient Email
Recipient Office Phone
Please enter the Account phone number from Salesforce.
Practice Name
Product
Please select the product that coincides with the primary reason for issuing this voucher.
Note - For single vision prescriptions, please use a coating or lens enhancement voucher.
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Via II Progressive Lenses
Via OfficePro
Relieve
Special Authorization
These enhancements below require special authorization. Please authorize only when absolutely necessary for the prescription.
None
Polarized
High Index 1.67
If selecting SunSync DO NOT authorize polarized.
Type: {{Voucher_Type}} Special Authorization: {{Special_Authorization}} Recipient Email: {{Recipient_Email}} Special Authorization_2: {{Special_Authorization_2}}