ReNu Infection Claim Inquiry Form

PERSONAL INFORMATION
First Name:
Last Name:
E-mail Address:
Address:

City:
State:
Zipcode:
Phone:	() - ext.

CONTACT LENS INFORMATION

How long have you worn contact lenses?
How long have you been using ReNu with MoistureLoc contact lens solution?
What were the dates of use?
Start Date Using
End Date Using

EYE INJURY INFORMATION

Have you developed:

Fungal eye infection
Bacterial eye infection
Any loss of vision

Have you suffered a permanent loss or change in vision?

I have suffered a permanent change or loss in my vision
My vision is the same as before my infection

Are you still able to wear contact lenses?

I am able to wear contact lenses
I can no longer wear contact lenses

Date of injury:

How long did you have to treat for your eye infection?

Did you miss any work?

How long did you use medications?

Were you using ReNu with MoistureLoc in the month prior to your eye infection?

Yes No

I have been treated with:

Antifungal eye drops
Antifungal ointment
Oral Antibiotic
Antifungal injection
Steroid eye drops
Eye Surgery

Corneal scraping
Corneal biopsy
Corneal debridement
Ultrasound of eye

Have you had a corneal transplant?

Yes No

If yes, please enter date:

Have you been given medications for your eye infection?

Yes No

Have you been told by a Doctor that you may need a corneal transplant?

Yes No

If yes to any of the above, please describe:

Additional Comments/Questions

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