Medical Information Request Form

Instructions:

  1. Adverse events or product quality complaints should not be reported using this form.
  2. Please complete all fields of the form.
Medical Information Request Form

Ocular Therapeutix Representative Contact Information

Name
Name
First
Last
Email

Healthcare Professional Contact Information

Name
Name
First
Last

Inquiry Details

Rush Delivery
Digital Signature

*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