The Varilux Challenge Review Submission Form

The Varilux Challenge Submission Form
As a valued partner, we want to know how Varilux lenses have supported you in providing your patients with the vision they deserve. Provide a short video or written testimonial describing the experience your patient had after switching to Varilux X Series Lenses and earn a $15 gift card.*
Practice Name *
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
To receive your $15 gift card, submit your video testimonial or written review now. *

I'd like to upload a video of my testimonial. I'll just type my written review. I don't wish to leave a testimonial, or receive a $15 gift card.
Choose the video recording of your testimonial and upload it here. *

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Share your review *
What progressive design was your patient previously wearing? *
Enter the name of your patient's previous lens design.
Rate your patient's experience with their Varilux lenses. *

★ ★★ ★★★ ★★★★ ★★★★★
I am currently an Essilor Expert. *

Yes No
Do you currently dispense Varilux Lenses? *

Yes No
Should be Empty:

The Varilux Challenge Submission Form