Consent

* Mandotory Fields

First Name*

First name is Required Invalid Last Name [Only Letters are Acceptable]

Last Name*

Last name is Required Invalid Last Name [Only Letters are Acceptable]

Clinic Name*

Clinic Name is required Invalid Clinic Name, Not more that 50 characters

Full Address*

Address is Required Invalid Address. Should consist of letter & number, not more that 100 characters

State*

State is Required

Phone Number*

Phone is Required Invalid Phone, Phone number should begin with country code 60 and follow with are code & 6 - 8 numbers

E-mail*

Email Address is Required Invalid Email Address

I have read and understand Viatris’ Terms and Conditions and Privacy Policy.

I consent to provide my Personal Data to Viatris: I agree that Viatris Inc., its affiliates and subsidiaries (“Viatris”) may use the above data to be published at Viatris Health Screening webpage which is accessible to the public. I understand and acknowledge that all personal data processed by Viatris is handled in accordance with local privacy laws and, where permissible, may be collected and processed in countries outside of the jurisdiction in which it was collected. I understand that my consent is voluntary, and I can withdraw my consent at any time. The withdrawal of consent will not affect the lawfulness of processing based on consent before its withdrawal. I acknowledge that I am not obliged to provide my personal data. However, if I do not provide the information, I may not, for example, be able to participate fully in activities managed by Viatris.

By clicking “SUBMIT” you confirm that the information you have provided above is correct, and you agree to Viatris’ processing of your personal data, including its transfer, where permissible, internationally and to third parties, in accordance with the Viatris Privacy Notice at www.viatris.com/en/privacy-policy

NON-2023-7763-21AUG2023

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