1. Your information

*Required information

*First name:
*Last name:
*Address:
*City:
*State:	--select a state-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY
*ZIP:
Phone number:
*E-mail address:
*Confirm e-mail address:
	Allergan, Inc. will never make your e-mail address available to third parties.

2. Please tell us about yourself

Have you seen a doctor within the past 12 months specifically for something related to your eyes?

• Yes
• No

If you answered “yes,” what kind of doctor did you visit?

• Ophthalmologist (eye doctor)
• Optometrist
• Primary care physician
• Another type of healthcare professional

If you were treated by an eye doctor within the past 12 months, did you talk about Chronic Dry Eye?

• Yes
• No

Do you use over-the-counter artificial tears (eye drops) for your dry eye-related problems?

• Yes
• No

If “yes,” how often do you use over-the-counter artificial tears?

• Three times or more a day
• Once a day
• More than two times per week but less than daily
• Once or twice a week
• Less than once a week

Which of the following, if any, over-the-counter artificial tears are you currently using or have you used recently?

• REFRESH^®
• Clear eyes^®
• GenTeal^®
• Moisture Eyes^™
• Systane^®
• Tears Naturale^®
• Thera^®Tears
• Visine^®
• Others
• None of the above

What, if anything, about the Chronic Dry Eye ad influenced you to contact us for the brochure?

• The description of Chronic Dry Eye in the ad sounded like the way my eyes feel
• I related to the people/images featured in the ad
• I have been using artificial tears but wasn’t satisfied with the results
• I wanted to learn more about Chronic Dry Eye
• Other

Other than over-the-counter artificial tears, have you ever received any dry eye medications or treatments?

• Yes
• No

If “yes,” what is the name of the treatment/medication?

3. Additional information

Yes, please activate a free subscription to Your Health in Sight^™, Allergan’s quarterly eye health newsletter.

Yes, Allergan, Inc. may use my information to help develop new products, services, programs, and materials, and contact me about additional products and programs I may find useful.

Yes, Allergan, Inc. may contact me in the future to invite my participation in research or get my comments on Chronic Dry Eye material.

4. Click to submit

This information is intended for residents of the United States.

REGISTRATION AND TRADEMARK INFORMATION
® and ™ marks owned by Allergan, Inc.
Clear eyes^® is a registered trademark of Prestige Brands, Inc.; GenTeal^® is a registered trademark of Novartis Pharmaceuticals Corporation; Moisture Eyes^™ is a trademark of Bausch & Lomb, Inc.; Systane^® and Tears Naturale^® are registered trademarks of Alcon, Inc.; Thera^®Tears is a registered trademark of Advanced Vision Research, Inc.; Visine^® is a registered trademark of Pfizer, Inc.