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Contact Us
ENQUIRY FORM
Type of Enquiry:

Request for Information
Request for Sample
Request for Action
Offering Suggestions

Type of Customer:

Health Care Professional
Consumer / End User
Distributor

Your Enquiry / Request: *
Customer Details
Customer Code: *
Customer Name: *
Address: *
Phone - - *
Email *
IMPLANT NOTIFICATION CARD INFORMATION:
Surgeon Details:
Surgeon's Name
Contact no: - -
Date of Surgery  Click Here to Pick Date *
Hospital Name: *
Address: *
Patient Details:
Patient Name *
Contact no: - - *
Address: *
Date of Birth  Click Here to Pick Date *
Gender :

Male Female

Education Level:

None High School College

Eye on which surgery was performed:

Right Left

Type of surgery Performed:

SICS MICS PHACO

Implant Lens Details:
Brand name: *
 Model / REF:   *
Diopter: *
 Date of Expiry:  Click Here to Pick Date *
Lot No: *
 Serial No:        *
  


Ellis Ophthalmic Technologies, Inc.

147-39, 175 Street,Suite # 128
Jamaica, NY - 11434, U.S.A.
Tel :(718)-656- 7390
Fax: (718) 656-7394
E-mail : info@eye-ellis.com

 


147-39, 175 Street, Suite # 128, Jamaica, NY - 11434, U.S.A.
Phone: (718)-656- 7390 Fax : (718) 656-7394. Email: info@eye-ellis.com
© 2002 Ellis Ophthalmic Technologies, Inc.
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