NEW ORDER FORM - PCI - Virtual Vision

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ORDER FORM

Virtual Eye Elite: $8,500.00
Virtual Eye Elite S: $10,000.00
Virtual Eye Pro: $12,000.00
Waggoner Extended Color Test: $1,500.00
Trial Lens Holder: $70.00

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Sales rep name

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Deal source

First name

Last name

Salutation

Salutation (other)

Company name

Phone number

Shipping information

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Address

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Select your device

Virtual Eye Elite Virtual Eye Elite S Virtual Eye Pro None

Device name

Choose your color

Please enter the email address you would like to access your VRVF Software with

Additional order details

Device list price each

Device discount per device (in USD)

Trial lens holder quantity

Trial lens holder price

Trial lens discount each (in USD)

How many additional years warranty does the customer want ($550 per/year)

0 1 2 3 4 5

Warranty discount per year (in USD)

Waggoner Extended Color Test Upgrade quantity

Waggoner Extended Color Test price (in USD)

Waggoner discount each (in USD)

Shipping ($70 for headsets)

Total before taxes

Terms and Conditions

Prices are not inclusive of sales tax or 2.9% credit card fee (if applicable). I understand the credit card fee and state tax will be applied to the final invoice based on state regulations.

I understand that sales tax is self-reporting if out of the state of Ohio.

By electronically signing here, I agree to the pricing and terms and conditions of this online form:

ABOUT US

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info@virtualvision.health
+1 754-300-6353
3692 Grand Ave, Miami, FL 33133

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