Medical Inquiry - Bausch + Lomb

MEDICAL INFORMATION REQUESTS

MEDICAL INFORMATION REQUEST FORM

This form is for Canadian Health Care providers only to submit a medical inquiry about a Bausch + Lomb prescription or OTC product sold in Canada.

This form is not intended to report Adverse Events. To report an Adverse Event or Product Quality Complaint for Bausch + Lomb products please call 1-888-459-5000.

Title *

First Name *

Last Name *

Email *

Confirm Email *

Province/territory *

Outside of Canada

Profession *

Other

Select the Bausch + Lomb division *

Rx:

Consumer/OTC:

Inquiry *

Please note that we may need to process your personal data in order for us to address your inquiry. By submitting your information, you confirm you have read and agree with the terms of our Legal Notice & Privacy Policy - Bausch + Lomb