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 a free service to patients in India who have been prescribed Latoprost RT, Latoprost-N, Synca, or Raiki, to help manage disease.

I hereby authorize the 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.