Order Online Please fill out the form below. You will be contacted within 24 business hours by one of our Patient Service Representatives to complete your order for vitrectomy surgery recovery equipment.Patient's First Name* Patient's Last Name* Contact Name (if not patient) Email Primary Phone*Alternate PhoneDelivery Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth (mm/dd/yyyy) MM slash DD slash YYYY Date of Surgery (mm/dd/yyyy) MM slash DD slash YYYY Surgeon Expected Length of Rental PackageBest Value Comfort PackageStandard Comfort PackageEconomy Comfort PackageFlex System Comfort PackageI would like help selectingOtherEmailThis field is for validation purposes and should be left unchanged.
