Contact Lens Solution Safety Report Form
Report any issues or concerns related to contact lens solution safety. Please complete the form below with as much detail as possible.
Your Full Name
*
First Name
Last Name
Your Contact Email or Phone Number
*
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Lens Solution Brand/Name
*
Product Lot or Batch Number
Type of Safety Issue Observed
*
Please Select
Cloudiness or discoloration
Unusual odor
Packaging defect
Eye irritation or discomfort
Other
Describe What Happened
*
Were the lenses used as directed?
*
Yes
No
Not sure
Immediate Action Taken (if any)
Would you like a follow-up regarding this report?
*
Yes, please contact me
No follow-up needed
Submit Report
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