Request for Office Materials

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 Name

Email*

Email

Phone*

Phone

Address*

Where should we ship the materials?

Street Address Address Line 2 City State ZIP Code

Please identify which materials you would like us to send you.

Payfordrops.com $5.00 off Information Flyer

LessDrops® Materials

LessDrops^® 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® Materials

Simple 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® 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® 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

Comments

If you would like to provide additional request or comments, please indicate those below.

Requestor Name*

Requestor Name

COVID-19 UPDATE