The following must be included in the Defective Claim Return to receive credit:

  1. The defective product
  2. A printed copy of the Defective Fitting Set Return Form (below)

"*" indicates required fields

MM slash DD slash YYYY

Reason For Return

Patient Contact (Insertion)*
Was the lens ever inserted into the patient’s eye?
Patient Injury*
This field is for validation purposes and should be left unchanged.