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