Request a free product sample and/or to become a reseller.

If you are a licensed eye care professional and would like to receive a free Tear Duct OccluderTM and/or become a reseller,  please fill out the following form. (* indicates required field) Upon verification of your information, we will mail you a free sample along with a reseller discount price.

    First Name*

    Last Name*

    Phone Number

    Email*

    Institution/Practice Name

    NPI Number*

    Practice Website*

    Street Address*

    City*

    State/Region*

    Zip/Postal Code*

    Country*

    Job Title