Alcon Account #
*
Clinic / Facility Name
*
I acknowledge I have read and understood the contents of this notification letter.
*
Yes
Name of Responder (First and Last)
*
Contact Email
*
Contact Phone Number
*
Units on Hand/Disposed:
*
Any units to return?
Yes
No
Lot / Batch Number
Quantity
Additional Units to be returned
Yes
No
Lot / Batch Number 2
Quantity 2
Additional Units to be returned
Yes
No
Lot / Batch Number 3
Quantity 3
Additional Units to be returned
Yes
No
Lot / Batch Number 4
Quantity 4
Additional Units to be returned
Yes
No
Lot / Batch Number 5
Quantity 5
Additional Units to be returned
Yes
No
Lot / Batch Number 6
Quantity 6
Additional Units to be returned
Yes
No
Lot / Batch Number 7
Quantity 7
Additional Units to be returned
Yes
No
Lot / Batch Number 8
Quantity 8
Additional Units to be returned
Yes
No
Lot / Batch Number 9
Quantity 9
Additional Units to be returned
Yes
No
Lot / Batch Number 10
Quantity 10
SUBMIT