On-Site Clinic Request Form

Have questions? Our team has answers! Direct inquiries to Scott Duhaime, Versant Health Product Manager: Scott.Duhaime@versanthealth.com.

Requirements

	Befitting (Telehealth)	OnSight
States Available	AZ, CA, CO, DC, FL, GA, IA, ID, LA, MA, MD, MI, MN, MO, MT, NE, NH, NJ, NY, PA, SC, TX, VA, VT, WA, WI	AZ, CA, CT, FL, GA, IL, IN, KY, MA, ME, MI, MN, NC, NH, NJ, NY, OH, PA, SC, TN, TX, WA, WI
Minimum Lead Time needed	Eight-to-12 weeks	Six weeks
Minimum Employees Required	400	100
Space Requirements	- Provide secure rooms, with a minimum 600 sq. ft. space (two 300 sq. ft. rooms preferable) to allow for the clinic and store - Provide additional locked storage room (minimum 200 sq. ft) - Electricity, Internet (land line preferred; minimum 30Mbps) - Provide access to loading dock and utilities - Elevator access (if second floor or higher)	- Exam area / conference room or office: at least 12' x 15' - Smaller office or open space near exam room for check-in, eyewear viewing, and purchasing - Electricity - Internet (10Mbps Wi-Fi or ethernet access)

Please select your current vision care administrator.*

Davis VisionSuperior Vision

Please choose the experience you are requesting. Select all that may apply.*

BefittingOnSight

Client Name*

First NameLast Name

Company Name*

Client Address (1)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address 1's Approximate Number of Employees*

Add Second Location?*

YesNo

Client Address (2)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address 2's Approximate Number of Employees*

Add Third Location?*

YesNo

Client Address (3)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address 3's Approximate Number of Employees*

Client Email Address*

example@example.com

Client Phone Number*

Area CodePhone Number

Client Preferred Start Date 1*

The number of clinic days is determined by the number of employees per location submitted.

Client Preferred Start Date 2*

The number of clinic days is determined by the number of employees per location submitted.

Client Preferred Start Date 3*

The number of clinic days is determined by the number of employees per location submitted.

Requestor Name*

First NameLast Name

Requestor Email*

example@example.com

Comments (Optional)