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Physicians

Doctors: Fill out the form below to receive free Comfort Solutions brochures to give your patients. In addition to our toll-free phone, fax and e-mail support, we call patients before, during and at the end of their rental period to check-in.

Practice Name:
Contact Name:
E-mail:
Phone:
Fax:
Number of Locations:
Shipping Address:
Number of FREE Brochures:
Retinal Physician(s):
Additional Information:
   
Additional Location #1
   
Contact Name:
E-mail Address:
Phone:
Fax:
Shipping Address:
Number of FREE Brochures:
Retinal Physician(s):
Additional Information:
   
Additional Location #2
   
Contact Name:
E-mail Address:
Phone:
Fax:
Shipping Address:
Number of FREE Brochures:
Retinal Physician(s):
Additional Information:

Thank you! We will mail brochures to you shortly.

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