BostonSight SCLERAL | Innovations

Lens Return Form

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Practice Name

Practice Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Practitioner Name

First

Last

Order Details

First Fit Order Date

Lens Order Number

Patient Full Name

Return Information

Diameter

R (OD) Quantity Returned

L (OD) Quantity Returned

Reason for Return

If "Other", please describe in detail

Your Name (Requestor)

First

Last

Your Email (Requestor)

L Date Name

A copy of this form along with detailed return instructions will be emailed to you once your return is approved. Do not return your lenses until you receive email confirmation.

BostonSight, 464 Hillside Avenue, Suite 205, Needham, MA 02494
Phone: 888-SCLERAL (888-725-3725)

Lens Return Form

Order Details

Return Information

Experience the BostonSight SCLERAL difference.