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Sign up to become a ForeseeHome referral partner by completing this form. You do not need to complete the form if your practice has previously ordered ForeseeHome for a patient. To change contact information or for questions about submitting a referral, please email practicesupport@notalvision.com or call Practice Engagement at 1-888-600-3112.

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Practice Information
Office Information
Prescriber Information
Alert Communication

Practice Information

Practice Name ^*

Practice Website

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Primary Practice Contact

Your practice’s main point of contact for Notal Vision

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Is the practice contact also a prescriber?

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Office Information

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Fax

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Primary Office Contact

Your office’s main point of contact for Notal Vision

Is the Office Contact the same as the Practice's Primary Contact?

First Name ^*

Last Name ^*

Email ^*

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Is the office contact also a prescriber?

Patient Alert Recipients

Patient Alert notifications inform you of a statistically significant change in a patient’s test. It is also your office’s prompt to contact the patient for a follow up visit and to log into the ForeseeHome Prescriber Portal or App to review the patient’s report. A monthly summary report for each patient will also be sent to each email address listed. Please list up to three recipients below (at least one is required).

Check here if the Office Contact should receive Patient Alert Notifications.

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Add Additional Offices

Check here to allow Notal Vision to share your participation as a prescribing practice through various online channels, including the ForeseeHome patient website “Find a Doctor” application.

Check this box to agree to receive product and disease-state information from Notal Vision and its affiliates, service providers, and co-promotion partners

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FORESEEHOME PRESCRIBERS

List all eye care professionals authorized to prescribe ForeseeHome.

Prescriber Details

Prescriber Details

Prescriber Details

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Last Name ^*

NPI ^*

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Speciality ^*

Phone ^*

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Office Location ^*

Check here for this prescriber to receive Patient Alert Notifications.

Email ^*

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Patient Alert Communication

Please select which of the following additional patient alert emails you would like to receive:

New prescription received

Patient onboarding complete

Notal Vision unable to reach patient

Patient declined onboarding process

Patient withdrew

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FDA Indication for Use

The ForeseeHome is intended for use in the detection and characterization of central and paracentral metamorphopsia (visual distortion) in patients with age-related macular degeneration, as an aid in monitoring progression of disease factors causing metamorphopsia including but not limited to choroidal neovascularization (CNV). It is intended to be used at home for patients with stable fixation.

The ForeseeHome AMD Monitoring Program is only available by physician order and is intended to be used as an addition to regular eye exams.

The technical component of the ForeseeHome AMD Monitoring Program is covered by Medicare, subject to its coverage requirements for the test, to assess patients with dry AMD who are at risk of developing wet AMD. Please refer to your local Medicare Administrative Contractor (MAC) for which the ordering physician resides concerning coverage availability for the physician professional services component of the test.