• ABOUT DRY EYE
  • Symptoms, Causes, and Diagnosis of Dry Eye
  • Treatments for Dry Eye
    • Artificial Tears
    • Prescription Options
    • Other Patient Options
• ABOUT LACRISERT^®
  • How LACRISERT^® Works
  • The Benefits of LACRISERT^®
  • Writing LACRISERT^®
  • How Patients Use LACRISERT^®
  • LACRISERT^® Efficacy Data
  • Patient Testimonials
• RESOURCES FOR YOU + YOUR PATIENTS
  • LACRISERT^® Sample Request
  • Customizable Tip Sheet
  • Valeant Patient Savings Program
  • Valeant Patient Assistance Program
  • Learn More About LACRISERT^®
  • Valuable Links
  • Presentations
• FAQs

LACRISERT^® Sample Request

Thank you for interest in receiving LACRISERT^® samples for your patients. Please follow the following steps.

Step 1:	Enter the required contact information below. Also, enter the quantity requested (limit of 5 sample packs).
Step 2:	Once the information is complete, press the submit button to view and print your request form.
Step 3:	Please sign and date the form.
Step 4:	Fax the request to (908) 927-1926 or mail to:
	Valeant Pharmaceuticals North America Attn: Customer Service 700 Route 202/206, Bridgewater, NJ 08807

Practitioner’s Name and Professional Designation*
State Medical License Number*
Practice Name*
Address*
City*
State*	Zip Code*
Select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Telephone Number*
E-mail Address*
(NDC 25010-805-08) LACRISERT® 5mg 10 Inserts per pack Quantity Request*: 1 2 3 4 5
Is this your first LACRISERT® sample request via the web site? Yes No
Have you received LACRISERT® samples from a sales representative? Yes No
Have you prescribed LACRISERT® previously? Yes No
How many dry eye patients do you treat on average per month? 0-20 21-40 41-60 61+
* Indicates required information.
YES, I would like Aton Pharma, Inc. to send me periodic updates about LACRISERT®.
Protecting Your Privacy In order to provide you with a better Web site experience and better features in the future, we ask you for your e-mail address. If you provide this data, you agree to allow Aton Pharma, Inc. to link your e-mail address to anonymous (non−personally-identifiable) information that you may have given us previously, or that may have been collected on other Aton Pharma, Inc. Web sites. We will not sell your e-mail address, and you will not receive e-mail from us that you have not agreed to receive.

Indications and Usage

LACRISERT^® is indicated in patients with moderate to severe Dry Eye syndromes, including keratoconjunctivitis sicca. LACRISERT^® is indicated especially in patients who remain symptomatic after an adequate trial of therapy with artificial tear solutions. LACRISERT^® is also indicated for patients with exposure keratitis, decreased corneal sensitivity, and recurrent corneal erosions.

Important Safety Information

LACRISERT^® is contraindicated in patients who are hypersensitive to hydroxypropyl cellulose. Instructions for inserting and removing LACRISERT^® should be carefully followed. If improperly placed, LACRISERT^® may result in corneal abrasion. Because LACRISERT^® may cause transient blurred vision, patients should be instructed to exercise caution when driving or operating machinery. Patients should be cautioned against rubbing the eye(s) containing LACRISERT^®.

The following adverse reactions have been reported, but were in most instances, mild and temporary: transient blurring of vision, ocular discomfort or irritation, matting or stickiness of eyelashes, photophobia, hypersensitivity, eyelid edema, and hyperemia.