Rebate Submission Form

First Name ^*

Last Name ^*

Address Line 1 ^*

Address Line 2

City ^*

State ^*

Zip Code ^*

Email Address ^*

Confirm Email Address ^*

DOB ^*

Would you like to receive emails on future offers from Menicon? ^*

YES NO

Which brand of contact lenses were you wearing prior to Miru? ^*

Product Purchased ^*

Eye Care Professional Name ^*

Purchase Date ^*

Upload Receipt: ^*

Please upload original sales receipt showing proof of payment for your eligible contact lens purchase.
Purchase must be made within 60 days of eye exam.
Circle contact lens purchase and date on receipt.
All receipts must be from the same eye care practitioner who prescribed your contacts, or from a location affiliated with that practitioner.
Acceptable file formats: jpg, png, pdf.
Max file size 2 mb

Enter all qualifying UPCs purchased along with quantities. ***UPC required for valid claim***

UPC 1 ^*

UPC 1 QTY^*

UPC 2

UPC 2 QTY

* denotes required field