Omisan.com - Customer Service: Complaint Form

Thank you. Your complaint will be immediatly processed by our Quality Assurance office.
Please properly fill in all the fields.

Complaint Form
Contact lens Wearer data
*	Name and Surname:
	Address:
*	Town:
*	Country:
*	e-mail:
	Telephone:
Your personal data will be managed in according to the Italian Privacy Law 675/96 to file your complaint
Product data
*	Product Name:
*	Lot Number (LOT):
	Purchase time:
	frequency usage:
*	Is the product available for tests?		Yes No
*	Problem occurred:

Anything else?:

.		.
Shop data
	Shop Name:
*	Town:
*	Country:


	* required field