Full Name *

Full Name of Person That Referred You *

Practice Name Where the Person Who Referred You Had Surgery *

Practice Name Where Your Surgery Took Place *

Your Email *

Implant Card Serial # *

Where to find serial number:

example STAAR Implant Card with sticker

Month and Year of Surgery *

Email of the Referring Friend *

Re-enter Email *

*Your gift card will be emailed from Amex

I consent to receive phone calls, text messages and emails from STAAR Surgical Company, including appointment reminders, scheduling updates, post-procedure instructions, billing notifications, and promotional or marketing messages such as special offers, new services, and practice updates. Message frequency varies. Message and data rates may apply. Reply STOP to opt out at any time. Reply HELP for assistance. Consent is not a condition of purchase.