Registration Form – Via Drishti

Registration
Form

IN-NON-2025-00195_Sep 2025

Name

Mobile No

Email Id

Hospital name / Clinic Name

Address

State

City

Dear Dr, would you be interested to have the glaucoma patient education 2d and 3d videos for you ?
YesNo

I hereby consent to receiving the details for the patient awareness website ViaDhrishti. I understand that my consent & enrolment in this activity is completely voluntary and that I have the right to decline this service if I wish to. I have read & fully understood the content of this form before signing it & I have had opportunity to ask question about use of my personal information.

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