Medical Information Request Form | Ocular Therapeutix

Medical Information Request Form

Instructions:

Adverse events or product quality complaints should not be reported using this form.
- Please report all Suspected Adverse Reactions to ocutx.pharmacovigilance@propharmagroup.com and Product Quality Complaints to ocutx.productcomplaint@propharmagroup.com.
Please complete all fields of the form.

"*" indicates required fields

Step 1 of 3 – OCULAR THERAPEUTIX REPRESENTATIVE CONTACT INFORMATION

OCULAR THERAPEUTIX REPRESENTATIVE CONTACT INFORMATION

Name

First Last

Email

Phone

HEALTHCARE PROFESSIONAL CONTACT INFORMATION

Name*

First Last

Title*

Hospital Affiliation*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Fax

Email*