Order Lacrifill

A convenient, safe and fast ordering process

Order Lacrifill^® quickly and securely using this form. Once submitted, your order request will be processed promptly and you will receive a confirmation by email.

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New or existing customer?

Have you ordered Lacrifill via this website before? *

Yes

Personal information

First name of medical ophthalmologist *

Last name medical ophthalmologist *

Medical Registration Number *

EIR Code *

Name of Clinic / Hospital *

Clinic / Hospital Address *

Name of person to receive delivery *

Delivery Address *

Email address *

Phone *

Preferred delivery time on Monday *

Preferred delivery time on Tuesday *

Preferred delivery time on Wednesday *

Preferred delivery time on Thursday *

Preferred delivery time on Friday *

Order Information

A pack of Lacrifill^® consists of 10 pre-filled syringes, each with 0.6ml of gel, containing enough gel to fully fill both inferior canaliculi of a single patient¹.

Product *

Quantity (number of packs) *

Shipping Information

Address *

City *

Postal code *

Country *

Delivery Notes

Billing Information

Address *

City *

Postal code *

Country *

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Order Lacrifill^®

A convenient, safe and fast ordering process

New or existing customer?

Personal information

Order Information

Shipping Information

Billing Information

Medical device vigilance

Welcome

Order Lacrifill®

A convenient, safe and fast ordering process

New or existing customer?

Personal information

Order Information

Shipping Information

Billing Information

Medical device vigilance

Welcome

Order Lacrifill^®