Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Please note: due to high demand, samples will take longer to arrive than expected. Only submit the form once as your submission has been received. Thank you for your patience. Eye Care Professional Sample Request Thank you for your interest in iVIZIA. We are only able to provide samples directly to Eye Care Professionals. Please visit your eye doctor to request a sample. Simply fill out the required fields below and click on the submit button.First Name *Last Name *SuffixNPI # *Primary Specialty *NoneOphthalmologyOptometryPractice Name *Email Address *Telephone *Street Address *We can no longer accept PO box addressesIf samples should go to the attention of another person than you, send samples to:Approximate number of dry eye patients per week? *I agree to the iVIZIA privacy policy terms *I agree to the iVIZIA privacy policy termsI would like to receive educational information and product announcements from iVIZIAI would like to receive educational information and product announcements from iVIZIASubmit Request
