MEDICAL INQUIRIES – Ocular Therapeutix

Instructions:

Adverse events or product quality complaints should not be reported using this form.^†
Please complete all fields of the form.

Medical Information Request Form

Ocular Therapeutix Representative Contact Information

Name

Phone

Healthcare Professional Contact Information

Name

First

Last

Title

Hospital Affiliation

Street Address

City

State

Zip Code

Phone

Fax

Inquiry Details

Select a product...

Select a product...

Inquiry Text

Delivery option...

Rush Delivery

YesNo

Digital Signature

I understand that checking this box constitutes my legal signature certifying that, this is an unsolicited request for medical information by a healthcare professional, and that the request is captured as the healthcare professional has intended.

*Required

^† You are encouraged to report Suspected Adverse Reactions. Please contact us: ocutx.pharmacovigilance@propharmagroup.com
1-800-339-8369 | Hours: 9:00AM-5:00PM Mon – Fri ET