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 Patient Information Sheets Patient Information Tear pads (2 pads of 50 will be sent unless otherwise noted in comments below) LessDrops® MaterialsLessDrops® Materials LessDrops® Easy to Use Bottle Instruction cards LessDrops EMR instructions cards (Quantity is 2. Please specify if you need more than that in the comment section below.) Simple Drops® MaterialsSimple Drops® Materials Simple Drops® Peel Offs Patient Brochures Simple Drops EMR instruction cards. (Quantity is 2. Please specify if you need more than that in the comment section below.) Total Tears® MaterialsTotal Tears® Materials Patient Brochures Total Tears EMR instruction cards (Quantity is 2. Please specify if you need more than that in the comment section below.) Dropless® MaterialsDropless® Materials Dropless EMR instruction cards (Quantity is 2. Please specify if you need more than that in the comment section below.) CommentsIf you would like to provide additional request or comments, please indicate those below. Requestor Name*Requestor Name
