Your Information

Your Full Name: *

Your Email: *

Re-enter Your Email: *

Practice Name Where Your Surgery Took Place: *

Practice City: *

Practice State: *

Month and Year of Surgery: *

Implant Card Serial Number (SN): *

The Implant Card was provided by your doctor after surgery, which contains information specific to your ICL that was implanted.

To locate the SN, look on the back of the card (boxed in red)

example STAAR Implant Card with sticker

Your Friend’s Information

Full Name of Person That Referred You: *

Your Friend’s Email: *

Re-enter Your Friend’s Email: *

Practice Name Where the Person Who Referred You Had Surgery: *

*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.