Name *

First Name

Last Name

Phone *

(###)

###

####

What types of dry eye/home care products do you stock? *

Please select each dry eye product you stock

Compress

Dry Eye Supplements

None

Other

What type of Dry Eye Treatment device do you have? *

Please select all that apply

Lipiflow

TearCare

Ilux

Meiboflow

IPL

Other

I don't have one

Yes, I'd like a sample of the World's Best Compress

Please provide address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name *

First Name

Last Name

Current Treatment Devices *

IPL

Lipiflow

TearCare

Meiboflow

Other

No Device currently

Current Dry Eye Products *

Please list the products you stock in clinic

Dry Eye Compress

Omega-3 supplement

Lid Scrub

Macular Degeneration supplement

Yes, I'd like to schedule a 10 minute call

MM

DD

YYYY

Please call me at this time

Hour

Minute

Second

AM PM

Samples of the World's Best Dry Eye Compress? *

No, I don't want a sample (even though I can put my Logo on it)

Yes, send me samples of the World's Best Compress

Phone *

Country

(###)

###

####

Name *

First Name

Last Name

Phone *

(###)

###

####

What Dry Eye Treatments do you offer? *

Select all that apply

IPL

Lipiflow

TearCare

Ilux

Miboflo

Dry Eye Compress

Dry Eye Supplements

Other

I don't offer any dry eye treatments currently