Evaluation Details
  GSE will provide one (1) Eyecon® to be used for an in store evaluation. The evaluation period is ten (10) consecutive days. Upon receiving a completed ‘Evaluation Request Form’ an evaluation date will be scheduled. Upon availability, GSE will ship an Eyecon to the contact at the address listed below. The contact person will be notified upon shipment.

To participate you agree to:
   Provide two (2) dates for your evaluation period separated by a minimum of 10 days.
 Upon receipt of the evaluation Eyecon, call (313) 253 - 1302 for a 3-5 minute product overview.
 Retain the packaging and return the Eyecon in good condition at the end of the 10 day evaluation period.
 Purchase the Eyecon if not returned after the 10 day evaluation or if damaged due to misuse.
 Participate in a 3 minute phone survey after the evaluation period.

Evaluation Dates Preferred (Both fields required)
First Date Choice: Pick a date Second Date Choice: Pick a date

Who is your software provider?
  Please select your software provider from this list: 

GSE agrees to:
   Provide an Eyecon in good condition for evaluation at no charge.
 Provide shipping to and from your facility at no charge.
 Provide training and technical support via phone at no charge.

Pharmacy Information
  Contact Name:  (required)
  Contact Title:  (required)
  Company:  (required)
  Street Address:  (required)
  City:  (required)
  State:  (required)
  Zip Code:  (required)
  Phone:  (required)
  Fax:  (required)
  Email:  (required)
  Sales Representative / Distributor:  (required)
  Promotional Code:
  Referred By: