www.myalcon.com
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Submitted URL: http://www.myalcon.com/
Effective URL: https://www.myalcon.com/professional/
Submission: On June 15 via api from US — Scanned from DE
Effective URL: https://www.myalcon.com/professional/
Submission: On June 15 via api from US — Scanned from DE
Form analysis
1 forms found in the DOMPOST https://webto.salesforce.com/servlet/servlet.WebToCase?encoding=UTF-8
<form
class="webform-submission-form webform-submission-add-form webform-submission-atiol-patient-satisfaction-progr-form webform-submission-atiol-patient-satisfaction-progr-add-form webform-submission-atiol-patient-satisfaction-progr-node-1571-form webform-submission-atiol-patient-satisfaction-progr-node-1571-add-form js-webform-submit-once js-webform-details-toggle webform-details-toggle"
data-drupal-selector="webform-submission-atiol-patient-satisfaction-progr-node-1571-add-form" action="https://webto.salesforce.com/servlet/servlet.WebToCase?encoding=UTF-8" method="post"
id="webform-submission-atiol-patient-satisfaction-progr-node-1571-add-form" accept-charset="UTF-8" data-once="form-updated webform-submit-once webform-details-toggle"
data-drupal-form-fields="edit-name-of-the-requestor-c,edit-email,edit-phone,edit-wc-name-of-requesting-asc-institution-c,edit-wl-alcon-account-number-c,edit-wc-address-c,edit-wc-city-state-zip-code-c,edit-wc-contact-name-c,edit-contactphone,edit-contactemail,edit-wc-serial-number-of-initial-atiol-c,edit-wc-model-and-diopter-of-initial-atiol-c,edit-wc-date-of-initial-atiol-implantation-c,edit-wc-date-of-atiol-explantation-c,edit-wc-serial-number-of-replacement-iol-c,edit-wc-model-and-diopter-of-replacement-iol-c,edit-wc-patient-stated-reason-for-explant-c,edit-wc-clinical-reason-for-explantation-c,edit-wc-explanted-lens-available-for-return-c-yes,edit-wc-explanted-lens-available-for-return-c-no,edit-wc-name-surgeon-performing-atiol-explant-c">
<div class="webform-required">
<span class="form-required"></span>Please complete each of the fields below. *Denotes mandatory fields.
</div>
<div data-drupal-selector="edit-step-2" id="edit-step-2" class="js-form-wrapper form-wrapper"><input data-drupal-selector="edit-orgid" type="hidden" name="orgid" value="00DG0000000gc7V">
<input data-drupal-selector="edit-returl" type="hidden" name="retURL" value="https://www.myalcon.com/form-confirmation-atiol/">
<input data-drupal-selector="edit-external" type="hidden" name="external" value="1">
<input data-drupal-selector="edit-recordtypeid" type="hidden" name="RecordTypeId" value="012G00000019HNVIA2">
<input data-drupal-selector="edit-case-type-ac-c" type="hidden" name="Case_Type_AC__c" value="Pending">
<input data-drupal-selector="edit-debug" type="hidden" name="debug" value="0">
<input data-drupal-selector="edit-debugemail" type="hidden" name="debugEmail" value="ravi-1.dubey@alcon.com">
<input data-drupal-selector="edit-origin" type="hidden" name="Origin" value="Website">
<div class="coh-style-form-elements js-form-wrapper form-wrapper" data-drupal-selector="edit-container-1" id="edit-container-1">
<div id="edit-contact-info" class="js-form-item form-item js-form-type-processed-text form-type-processed-text js-form-item- form-item- form-no-label">
<p class="coh-style-form-sub-heading">Please complete each of the fields below. *Denotes mandatory fields.</p>
<p class="coh-color-systane-blue"> </p>
<p class="coh-style-form-heading"><span>Contact Information (Person completing this request):</span></p>
</div>
<div class="textbox-style js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-name-of-the-requestor__c form-item-name-of-the-requestor__c form-no-label">
<label for="edit-name-of-the-requestor-c" class="visually-hidden js-form-required form-required">*Name</label>
<input data-webform-required-error="This field is required " pattern="^[a-zA-Z ]*$" data-webform-pattern-error="Please enter letters only." data-drupal-selector="edit-name-of-the-requestor-c" type="text" id="edit-name-of-the-requestor-c"
name="Name_of_the_requestor__c" value="" size="60" maxlength="255" placeholder="*Name" class="form-text required" required="required" aria-required="true" data-once="webform-required-error">
</div>
<div class="js-form-item form-item js-form-type-email form-type-email js-form-item-email form-item-email form-no-label">
<label for="edit-email" class="visually-hidden js-form-required form-required">*Email address</label>
<input autocomplete="off" data-webform-required-error="This field is required " data-drupal-selector="edit-email" type="email" id="edit-email" name="email" value="" size="60" maxlength="254" placeholder="*Email address"
class="form-email required" required="required" aria-required="true" data-once="webform-required-error">
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-phone form-item-phone form-no-label">
<label for="edit-phone" class="visually-hidden js-form-required form-required">*Phone number</label>
<input autocomplete="off" data-webform-required-error="This field is required " data-drupal-selector="edit-phone" type="text" id="edit-phone" name="phone" value="" size="60" maxlength="255" placeholder="*Phone number"
class="form-text required" required="required" aria-required="true" data-once="webform-required-error">
</div>
</div>
<div data-drupal-selector="edit-container-2" id="edit-container-2" class="js-form-wrapper form-wrapper">
<div id="edit-requestor-info" class="js-form-item form-item js-form-type-processed-text form-type-processed-text js-form-item- form-item- form-no-label">
<p class="coh-style-form-heading"><span>Requestor Information:</span></p>
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wc-name-of-requesting-asc-institution__c form-item-wc-name-of-requesting-asc-institution__c form-no-label">
<label for="edit-wc-name-of-requesting-asc-institution-c" class="visually-hidden js-form-required form-required">Name of requesting ASC / Institution</label>
<input autocomplete="off" data-webform-required-error="This field is required " data-drupal-selector="edit-wc-name-of-requesting-asc-institution-c" type="text" id="edit-wc-name-of-requesting-asc-institution-c"
name="WC_Name_of_requesting_ASC_Institution__c" value="" size="60" maxlength="255" placeholder="*Name of requesting ASC / Institution" class="form-text required" required="required" aria-required="true" data-once="webform-required-error">
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wl-alcon-account-number__c form-item-wl-alcon-account-number__c form-no-label">
<label for="edit-wl-alcon-account-number-c" class="visually-hidden">Account number</label>
<input data-drupal-selector="edit-wl-alcon-account-number-c" type="text" id="edit-wl-alcon-account-number-c" name="WL_Alcon_Account_Number__c" value="" size="60" maxlength="255" placeholder="Account number" class="form-text">
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wc-address__c form-item-wc-address__c form-no-label">
<label for="edit-wc-address-c" class="visually-hidden js-form-required form-required">Address</label>
<input data-webform-required-error="This field is required " data-drupal-selector="edit-wc-address-c" type="text" id="edit-wc-address-c" name="WC_Address__c" value="" size="60" maxlength="255" placeholder="*Address" class="form-text required"
required="required" aria-required="true" data-once="webform-required-error">
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wc-city-state-zip-code__c form-item-wc-city-state-zip-code__c form-no-label">
<label for="edit-wc-city-state-zip-code-c" class="visually-hidden">City, state, zip code</label>
<input data-drupal-selector="edit-wc-city-state-zip-code-c" type="text" id="edit-wc-city-state-zip-code-c" name="WC_City_state_zip_code__c" value="" size="60" maxlength="255" placeholder="City, state, zip code" class="form-text">
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wc-contact-name__c form-item-wc-contact-name__c form-no-label">
<label for="edit-wc-contact-name-c" class="visually-hidden">Contact name</label>
<input data-drupal-selector="edit-wc-contact-name-c" type="text" id="edit-wc-contact-name-c" name="WC_Contact_Name__c" value="" size="60" maxlength="255" placeholder="Contact name" class="form-text">
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-contactphone form-item-contactphone form-no-label">
<label for="edit-contactphone" class="visually-hidden">Contact phone number</label>
<input autocomplete="off" data-drupal-selector="edit-contactphone" type="text" id="edit-contactphone" name="contactphone" value="" size="60" maxlength="255" placeholder="Contact phone number" class="form-text">
</div>
<div data-webform-states-no-clear="" class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-contactemail form-item-contactemail form-no-label">
<label for="edit-contactemail" class="visually-hidden">Contact email address</label>
<input autocomplete="off" pattern="[a-z0-9._%+-]+@[a-z0-9.-]+\.[a-z]{2,}$" data-webform-pattern-error="Please enter valid email only." data-drupal-selector="edit-contactemail" type="text" id="edit-contactemail" name="contactemail" value=""
size="60" maxlength="255" placeholder="Contact email address" class="form-text" data-once="webform-required-error">
</div>
</div>
<div data-drupal-selector="edit-container-3" id="edit-container-3" class="js-form-wrapper form-wrapper">
<div id="edit-procedure-info" class="js-form-item form-item js-form-type-processed-text form-type-processed-text js-form-item- form-item- form-no-label">
<p class="coh-style-form-heading"><span>Procedure Information:</span></p>
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wc-serial-number-of-initial-atiol__c form-item-wc-serial-number-of-initial-atiol__c form-no-label">
<label for="edit-wc-serial-number-of-initial-atiol-c" class="visually-hidden js-form-required form-required">*Serial number of initial ATIOL</label>
<input autocomplete="off" data-webform-required-error="This field is required " data-drupal-selector="edit-wc-serial-number-of-initial-atiol-c" type="text" id="edit-wc-serial-number-of-initial-atiol-c"
name="WC_Serial_number_of_initial_ATIOL__c" value="" size="60" maxlength="255" placeholder="*Serial number of initial ATIOL" class="form-text required" required="required" aria-required="true" data-once="webform-required-error">
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wc-model-and-diopter-of-initial-atiol__c form-item-wc-model-and-diopter-of-initial-atiol__c form-no-label">
<label for="edit-wc-model-and-diopter-of-initial-atiol-c" class="visually-hidden">Model and diopter of initial ATIOL</label>
<input data-drupal-selector="edit-wc-model-and-diopter-of-initial-atiol-c" type="text" id="edit-wc-model-and-diopter-of-initial-atiol-c" name="WC_Model_and_diopter_of_initial_ATIOL__c" value="" size="60" maxlength="255"
placeholder="Model and diopter of initial ATIOL" class="form-text">
</div>
<div data-webform-states-no-clear="" class="js-form-item form-item js-form-type-date form-type-date js-form-item-wc-date-of-initial-atiol-implantation__c form-item-wc-date-of-initial-atiol-implantation__c form-no-label">
<label for="edit-wc-date-of-initial-atiol-implantation-c" class="visually-hidden js-form-required form-required">*Date of initial ATIOL implantation</label>
<input placeholder="*Date of initial ATIOL implantation" data-webform-required-error="This field is required " type="text" data-drupal-date-format="m/d/Y" data-drupal-selector="edit-wc-date-of-initial-atiol-implantation-c"
id="edit-wc-date-of-initial-atiol-implantation-c" name="WC_Date_of_initial_ATIOL_implantation__c" value="" class="form-text required hasDatepicker" required="required" aria-required="true" data-once="webform-required-error datePicker"
autocomplete="chrome-off-79752995">
</div>
<div class="js-form-item form-item js-form-type-date form-type-date js-form-item-wc-date-of-atiol-explantation__c form-item-wc-date-of-atiol-explantation__c form-no-label">
<label for="edit-wc-date-of-atiol-explantation-c" class="visually-hidden js-form-required form-required">*Date of ATIOL explantation</label>
<input placeholder="*Date of ATIOL explantation" data-webform-required-error="This field is required " type="text" data-drupal-date-format="m/d/Y" data-drupal-selector="edit-wc-date-of-atiol-explantation-c"
id="edit-wc-date-of-atiol-explantation-c" name="WC_Date_of_ATIOL_explantation__c" value="" class="form-text required hasDatepicker" required="required" aria-required="true" data-once="webform-required-error datePicker"
autocomplete="chrome-off-79036607">
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wc-serial-number-of-replacement-iol__c form-item-wc-serial-number-of-replacement-iol__c form-no-label">
<label for="edit-wc-serial-number-of-replacement-iol-c" class="visually-hidden js-form-required form-required">*Serial number of replacement IOL</label>
<input autocomplete="off" data-webform-required-error="This field is required " data-drupal-selector="edit-wc-serial-number-of-replacement-iol-c" type="text" id="edit-wc-serial-number-of-replacement-iol-c"
name="WC_Serial_number_of_replacement_IOL__c" value="" size="60" maxlength="255" placeholder="*Serial number of replacement IOL" class="form-text required" required="required" aria-required="true" data-once="webform-required-error">
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wc-model-and-diopter-of-replacement-iol__c form-item-wc-model-and-diopter-of-replacement-iol__c form-no-label">
<label for="edit-wc-model-and-diopter-of-replacement-iol-c" class="visually-hidden js-form-required form-required">*Model and diopter of replacement IOL</label>
<input autocomplete="off" data-webform-required-error="This field is required " data-drupal-selector="edit-wc-model-and-diopter-of-replacement-iol-c" type="text" id="edit-wc-model-and-diopter-of-replacement-iol-c"
name="WC_Model_and_diopter_of_replacement_IOL__c" value="" size="60" maxlength="255" placeholder="*Model and diopter of replacement IOL" class="form-text required" required="required" aria-required="true" data-once="webform-required-error">
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wc-patient-stated-reason-for-explant__c form-item-wc-patient-stated-reason-for-explant__c form-no-label">
<label for="edit-wc-patient-stated-reason-for-explant-c" class="visually-hidden">Patient's stated reason for requested explantation</label>
<input data-drupal-selector="edit-wc-patient-stated-reason-for-explant-c" type="text" id="edit-wc-patient-stated-reason-for-explant-c" name="WC_Patient_stated_reason_for_explant__c" value="" size="60" maxlength="255"
placeholder="Patient's stated reason for requested explantation" class="form-text">
</div>
<div class="js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wc-clinical-reason-for-explantation__c form-item-wc-clinical-reason-for-explantation__c form-no-label">
<label for="edit-wc-clinical-reason-for-explantation-c" class="visually-hidden js-form-required form-required">*Clinical reason for explantation</label>
<input data-webform-required-error="This field is required " data-drupal-selector="edit-wc-clinical-reason-for-explantation-c" type="text" id="edit-wc-clinical-reason-for-explantation-c" name="WC_Clinical_reason_for_explantation__c" value=""
size="60" maxlength="255" placeholder="*Clinical reason for explantation" class="form-text required" required="required" aria-required="true" data-once="webform-required-error">
</div>
<div class="js-form-item form-item js-form-type-radios form-type-radios js-form-item-wc-explanted-lens-available-for-return__c form-item-wc-explanted-lens-available-for-return__c form-no-label" data-once="webform-radios-required">
<label for="edit-wc-explanted-lens-available-for-return-c" class="visually-hidden js-form-required form-required">*Is the explanted lens available for return?</label>
<div id="edit-wc-explanted-lens-available-for-return-c" class="js-webform-radios webform-options-display-side-by-side">
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-wc-explanted-lens-available-for-return__c form-item-wc-explanted-lens-available-for-return__c">
<input data-webform-required-error="This field is required " data-drupal-selector="edit-wc-explanted-lens-available-for-return-c-yes" type="radio" id="edit-wc-explanted-lens-available-for-return-c-yes"
name="WC_explanted_lens_available_for_return__c" value="Yes" checked="checked" class="form-radio" data-once="webform-required-error">
<label for="edit-wc-explanted-lens-available-for-return-c-yes" class="option">Yes</label>
</div>
<div class="js-form-item form-item js-form-type-radio form-type-radio js-form-item-wc-explanted-lens-available-for-return__c form-item-wc-explanted-lens-available-for-return__c">
<input data-webform-required-error="This field is required " data-drupal-selector="edit-wc-explanted-lens-available-for-return-c-no" type="radio" id="edit-wc-explanted-lens-available-for-return-c-no"
name="WC_explanted_lens_available_for_return__c" value="No" class="form-radio" data-once="webform-required-error">
<label for="edit-wc-explanted-lens-available-for-return-c-no" class="option">No</label>
</div>
</div>
</div>
<div class="webform-element--title-inline js-form-item form-item js-form-type-textfield form-type-textfield js-form-item-wc-name-surgeon-performing-atiol-explant__c form-item-wc-name-surgeon-performing-atiol-explant__c">
<label for="edit-wc-name-surgeon-performing-atiol-explant-c">Name of surgeon performing ATIOL explantation</label>
<input data-drupal-selector="edit-wc-name-surgeon-performing-atiol-explant-c" type="text" id="edit-wc-name-surgeon-performing-atiol-explant-c" name="WC_Name_surgeon_performing_ATIOL_explant__c" value="" size="60" maxlength="255"
placeholder="Name of surgeon performing ATIOL explantation" class="form-text">
</div>
</div>
</div>
<div data-drupal-selector="edit-actions" class="form-actions js-form-wrapper form-wrapper" id="edit-actions"><input class="webform-button--submit button button--primary js-form-submit form-submit" data-drupal-selector="edit-submit" type="submit"
id="edit-submit" value="Submit">
</div>
</form>
Text Content
U.S. Customers Online Ordering for Surgical Supplies and Contact Lenses Go to U.S. Login REQUEST AN ONLINE ORDERING ACCOUNT U.S. Customers Digital Platform Connecting You to Your Patients and Providing Hassle-Free Contact Lenses to Patients through Your Practice Go to Marlo REQUEST A DEMO GET IN TOUCH WITH US Please complete each of the fields below. *Denotes mandatory fields. Please complete each of the fields below. *Denotes mandatory fields. Contact Information (Person completing this request): *Name *Email address *Phone number Requestor Information: Name of requesting ASC / Institution Account number Address City, state, zip code Contact name Contact phone number Contact email address Procedure Information: *Serial number of initial ATIOL Model and diopter of initial ATIOL *Date of initial ATIOL implantation *Date of ATIOL explantation *Serial number of replacement IOL *Model and diopter of replacement IOL Patient's stated reason for requested explantation *Clinical reason for explantation *Is the explanted lens available for return? Yes No Name of surgeon performing ATIOL explantation X Skip to main content PROFESSIONAL LEVEL 1 * Cataract * Refractive * Vitreoretinal * OTC * Prescription Drugs * Contact Lenses * Resources US MyAlcon for Consumers Hi John Smith john.doe@mail.com PROFESSIONAL LEVEL 1 * Cataract * Refractive * Vitreoretinal * OTC * Prescription Drugs * Contact Lenses * Resources Log out Shopping Cart MyAlcon for Consumers My Alcon | United States This page is available in English. Select below for other countries. Select another country PARTNERS IN PATIENT FOCUSED INNOVATION We aspire to lead the world in innovating life-changing vision and eye care products because when people see brilliantly, they live brilliantly. BRING YOUR PRACTICE’S VISION TO LIFE CATARACT SURGERY REFRACTIVE TECHNOLOGY VITREORETINAL SURGERY PROFESSIONAL RESOURCES CONTACT LENS SOLUTION We’re committed to helping you find the right contact lens solutions for your patients. SEE OUR CONTACT LENS SOLUTIONS EYE CARE PRODUCTS Our aim is to increase awareness of dry eyes and eye health, focusing on the importance of tear film for both eye health and vision. EXPLORE ALCON EYE CARE PRODUCTS CONTACT LENSES When it comes to contact lenses, one size doesn’t fit all. We’re here to help you find the right contact lenses to fit your patients lifestyle and vision needs. SEE OUR CONTACT LENSES ALCON EXPERIENCE ACADEMY Discover a non-promotional training and education resource for eye care professionals. GET TRAINING & RESOURCES WE ARE ALCON We help the world see, look and feel better. And after our first 70 years, we are just getting started. Discover our story. ©2022 Alcon Inc. 1/22 US-SG-2200009 * Cataract Surgical Equipment * IOLs * Disposables * Refractive Technology * Surgical Retina * Contact Lenses * OTC * Prescription Drugs * Support Center * Alcon Experience Academy * Marketing Portal * Alcon Science * COVID Resources * Contact Us United States * Privacy Notices * Cookie Notice * Your Privacy Choices * Terms of Use 1. Strictly Necessary Cookies 2. Functional Cookies 3. Targeting Cookies 4. Performance Cookies. 5. Social Media Cookies Close 1. Strictly Necessary Cookies Close 2. Functional Cookies Close 3. Targeting Cookies. Close 4. Performance Cookies. Close. 5. Social Media Cookies By clicking “Accept All Cookies”, you agree to the storing of cookies on your device to enhance site navigation, analyze site usage, and assist in our marketing efforts. Reject All Accept All Cookies Cookies Settings PRIVACY PREFERENCE CENTER When you visit any website, it may store or retrieve information on your browser, mostly in the form of cookies. This information might be about you, your preferences or your device and is mostly used to make the site work as you expect it to. The information does not usually directly identify you, but it can give you a more personalized web experience. Because we respect your right to privacy, you can choose not to allow some types of cookies. Click on the different category headings to find out more and change our default settings. However, blocking some types of cookies may impact your experience of the site and the services we are able to offer. More Information MANAGE CONSENT PREFERENCES STRICTLY NECESSARY COOKIES Always Active These cookies are necessary for the website to function and cannot be switched off in our systems. They are usually only set in response to actions made by you which amount to a request for services, such as setting your privacy preferences, logging in or filling in forms. You can set your browser to block or alert you about these cookies, but some parts of the site will not then work. These cookies do not store any personally identifiable information. View Vendor Details FUNCTIONAL COOKIES Functional Cookies These cookies enable the website to provide enhanced functionality and personalisation. They may be set by us or by third party providers whose services we have added to our pages. If you do not allow these cookies then some or all of these services may not function properly. View Vendor Details TARGETING COOKIES Targeting Cookies These cookies may be set through our site by our advertising partners. They may be used by those companies to build a profile of your interests and show you relevant adverts on other sites. 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They are capable of tracking your browser across other sites and building up a profile of your interests. This may impact the content and messages you see on other websites you visit. If you do not allow these cookies you may not be able to use or see these sharing tools. View Vendor Details Back Button VENDORS LIST Search Icon Filter Icon Clear checkbox label label Apply Cancel Consent Leg.Interest checkbox label label checkbox label label checkbox label label Reject All Confirm My Choices Wir haben bemerkt, dass Sie möglicherweise in Germany sind. Inhalte für Ihr Land oder Ihre Region wählen? Germany Germany Argentina Australia Austria Belgium (NL) Belgium (FR) Brazil Canada (FR) Canada (EN) Chile Czech Republic Denmark Ecuador Egypt Finland France Greece India Italy Japan South Korea Mexico Netherlands Norway Peru Polska Portugal Russia Switzerland South Africa Spain Sweden Taiwan Turkey United Kingdom Caribbean Latin America International Gehen