Request For Free Sample of EverTears Your Name(Required) First Last Provide Full Email To Receive Code for Free Sample Box of EverTears(Required) Please Enter Your Age in This Box(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Code Did Your Doctor or Eye Care Professional Say That You Have Chronic Dry Eyes?(Required)Did Your Doctor or Eye Care Professional Say That You Have Chronic Dry Eyes? No - But My Eyes are Always Dry & Irritated Yes On a scale of 1 to 5 Below, Please Check the Box That Best Describes Your Level of Dry Eye Discomfort on an Average Day - - Please Only Check ONE Box(Required)On a scale of 1 to 5 Below, Please Check the Box That Best Describes Your Level of Dry Eye Discomfort on an Average Day - - Please Only Check ONE Box 1 - Occasional Mild Discomfort and/or Watery Eyes 2 - Mild Discomfort and/or Watery Eyes Multiple Times a Day 3 - Occasional Significant Discomfort and/or Watery Eyes 4 - Consistent Significant Discomfort and/or Watery Eyes 5 - Severe Discomfort and/or Watery Eyes - - Makes it Difficult to Read, Watch TV or Drive at Night (or other activities) How Do You Treat Your Dry Eyes Today? Check as many answers as apply.(Required)How Do You Treat Your Dry Eyes Today? Check as many answers as apply. Artificial Tears Warm Compress (purchased) Eyelid Cleaning wipes (purchased) Heat Therapy in Doctor's Office (e.g. LipiFlow, iLux, UV Light, etc) Heated Masks (purchased) Home Remedies (e.g. warm washcloth, heated rice bag, other) Consent for Email Contact(Required) I agree to receive email communications from ThermaMEDx about free samples, special savings or news.CommentsThis field is for validation purposes and should be left unchanged. Δ
