Would you like to request patient materials for your office? Please fill out the form below and we will ship them directly to you.Name*Name First Last Clinic/Surgery Center Name*Clinic/Surgery Center NameEmail*Email Phone*PhoneAddress*Where should we ship the materials? Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please identify which materials you would like us to send you.Payfordrops.com $5.00 off Information Flyer Payfordrops.com $5.00 Info Flyer LessDrops® MaterialsLessDrops® Materials LessDrops® Prescription Information for Patients (50 sheets per pad, please indicate in the box below if you need more than 2 pads) Simple Drops® MaterialsSimple Drops® Materials Simple Drops® Prescription Information for Patients (50 sheets per pad, please indicate in the box below if you need more than 2 pads) Simple Drops® Peel Offs Patient Brochures Total Tears® MaterialsTotal Tears® Materials Total Tears® Prescription Information for Patients (50 sheets per pad, please indicated in the box below if you need more than 2 pads) Patient Brochures Dropless® MaterialsDropless® Materials Dropless Prescription Information for Patients (50 sheets per pad, please indicated in the box below if you need more than 2 pads) Dropless Payment information cards CommentsIf you would like to provide additional request or comments, please indicate those below. Requestor Name*Requestor Name
