Name *

First Name

Last Name

I use artificial tears (also known as over-the-counter lubricant eye drops) often. *

Yes

No

I usually carry artificial tears with me wherever I go. *

Yes

No

I have tried multiple types of over-the-counter artificial tears.

Yes

No

My dry eyes are getting worse.

Yes

No

Dry eyes affect my daily activities.

Yes

No

List all previous treatments you have had for your dry eye symptoms. *

check all that apply

Artificial Tears

Restasis/Xiidra/Cequa

Serum Tears

Lipiflow/Miboflow/Ilux

Scleral Lenses

Amniotic Membrane

Steroid Eye Drops

Meibomian Gland Probing