Appointment Request Form

*PARENT'S / CAREGIVER'S NAME: *CHILD'S FIRST NAME: *CHILD'S MONTH/YEAR OF BIRTH: *PARENT'S / CAREGIVER'S EMAIL: *PARENT'S / CAREGIVER'S MOBILE: *ARE YOU INTERESTED TO FIND MORE ABOUT MYOPIA CONTROL PRODUCTS *WHICH EYE CARE PROFESSIONAL WOULD YOU LIKE TO VISIT *DESIRED APPOINTMENT DATE: *DESIRED APPOINTMENT TIME:

With your consent, Johnson & Johnson International (Singapore) Pte Ltd (Company/We/Us), will collect, use, and process your and your child’s personal data to enable us [i] arrange appointment booking with the selected Eye Care Practitioner based on the provided details, [ii] include you in the Company’s Customer Relationship Management database, and [iii] send you eye healthcare product information and updates, promotional materials and marketing communications. We process personal data in accordance with our Privacy Policy which you may view at [https://www.seeyourabiliti.com/sg/parents/privacy-policy]. If you do not provide us your and your child’s personal information, we would be unable to carry out the above purposes. We may disclose your and your child’s personal information to Johnson and Johnson affiliates and to our selected Eye Care Professionals and our authorized service providers for the purposes described in this Privacy Notice.

Yes, I agree to receive messages on eye healthcare products and services, events, programs and activities, and marketing and promotional communications from J&J, through SMS, email, or other media platforms.

*Mandatory fields