• 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
  • Aton Patient Savings Program
  • Aton PatientCARE^SM 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 877-286-6649 or mail to:
	Aton Pharma Fulfillment Center 800 Woodland Prime, Suite 200 Menomonee Falls, WI 53051

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.

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
Do not use LACRISERT^® if you are allergic to hydroxypropyl cellulose. Instructions for inserting and removing LACRISERT^® should be carefully followed. If improperly placed, LACRISERT^® may result in a scratch to the cornea of your eye. Because LACRISERT^® may cause temporary blurred vision, please use caution when driving or operating machinery. Rubbing the eye(s) containing LACRISERT^® should be avoided. You should always discuss this safety information with your doctor. The following adverse reactions have been reported but were in most instances mild and temporary: temporary blurring of vision, eye discomfort or irritation, matting or stickiness of eyelashes, increased sensitivity to light, eyelid swelling, and eye redness. Talk to your doctor if you have side effects that bother you or that do not go away. You are encouraged to report side effects of prescription drugs to the FDA. Visit www.FDA.gov/medwatch or call 1-800-FDA-1088.