www.myalcon.com Open in urlscan Pro
2606:4700::6812:896f  Public Scan

Submitted URL: http://www.myalcon.com/
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 DOM

POST https://webto.salesforce.com/servlet/servlet.WebToCase?encoding=UTF-8

<form
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  <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">
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    <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">&nbsp;</p>
        <p class="coh-style-form-heading"><span>Contact Information (Person completing this request):</span></p>
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        <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">
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        <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">
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        <label for="edit-wc-name-of-requesting-asc-institution-c" class="visually-hidden js-form-required form-required">Name of requesting ASC / Institution</label>
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      <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">
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      <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">
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        <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">
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      <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>
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          <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>
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  </div>
</form>

Text Content

U.S. Customers

Online Ordering for Surgical Supplies and Contact Lenses

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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

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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

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Hi John Smith

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PROFESSIONAL LEVEL 1

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