Dry Eye Supply Order Form
Full Name
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Month
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Day
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2 digit month, 2 digit day, 4 digit year
E-mail
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Contact Number
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Billing Address
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Is shipping address same as billing address?
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Shipping Adress
Street Address Line 2
Special Instructions
My Products
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Oasis TEARS® PLUS Preservative-Free Lubricant Eye Drops
$24.00
$
24.00
30 vials/pack
Quantity
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Item subtotal:
$0.00
$
0.00
Blephadex Eyelid Wipes
$22.00
$
22.00
30 wipes/pack
Quantity
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9
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HydroEye® Vitamin Supplement
$35.00
$
35.00
120 sofgels/pack
Quantity
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Retaine MGD Ophthalmic Eye Drops
$19.50
$
19.50
30 vials/pack
Quantity
0
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Bruder Moist Heat Eye Compress
$24.00
$
24.00
Quantity
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Subtotal
$0.00
$
0.00
Shipping
$0.00
$
0.00
Total
$0.00
$
0.00
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