Eyedrops-Questionnaire

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Name *

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Last

Date of birth

Address

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Which product have you used? EzriCare Artificial TearsDelsam Pharmacy Artificial TearsOther

Have you had any of these symptoms? Please select all that apply.

• Blurry Vision
• Eye pain or irritations
• Redness in the eye or eyelids
• Sensations of something in your eye
• Discharge from the eye
• Other

Did your eyes ever get infected?YesNo

Briefly describe what happened?

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