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.

Patient Information Sheets

Patient Information Tear pads (2 pads of 50 will be sent unless otherwise noted in comments below)

LessDrops® Materials

LessDrops^® 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® Materials

Simple 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® 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® Materials

Dropless EMR instruction cards (Quantity is 2. Please specify if you need more than that in the comment section below.)

Comments

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

Requestor Name*

Requestor Name