HCP Intake Form

Note: Fields marked with asterisk (*) are mandatory.

Country*

SELECT YOUR COUNTRY

Salutation* Salutation is required

Title * Title is required

First Name*

Last Name*

Email*

Confirm Email*

Hospital / Clinic / Company Name*

Role / Function*

TOPICS OF INTEREST *

Cataract

Microscopes

Retina

Refractive

Glaucoma

You must select atleast one speciality.

* I consent that “Bausch + Lomb” as the data controller (for more details please consult the HCP Privacy Notice below) is processing my personal data to send marketing communications and newsletters in order to share information about products and services and develop our professional relationship by using my e-mail address or any other way of communication (e.g. mail, fax, phone).

Please enter a valid phone number with proper country code / minimum 9 digit number.

Both Email and Confirm Email should be same.

Phone number must be in proper format i.e +xx xxxxxxxxxx

Please provide a complete email address. ' ' is missing '.com' or '.net' or '.edu'.

Please provide only one '.' in the email address.

' Please provide atlest one '.' in the email address followed by valid domain extension.

By submitting your information, you confirm you have read and agree with the terms of our HCP Privacy Notice.

You may withdraw your consent at any given time, by accessing your preference center when you receive
any email from us.
To learn more about how we respect your privacy and process your data and also about your rights, please consult our HCP Privacy Notice.