By sharing the details i hereby authorize the service provider & its employees to collect and process my personal information for the purpose of enabling me to participate in Glaucoma patient support program . This program is free service to patients in India who have been prescribed Careprost LS , to help manage disease.

I hereby Authorize service provider to :

• Collect personal information from me through toll free number, Link etc.
• Provide education on disease condition through Web videos
• Follow up with me telephonically for assistance in Glaucoma patient support program