Information for Potential Participants - Protocol Number C-02-27

ONLINE ENQUIRY FORM

We will treat your personal information confidentially and will not use your personal data for any commercial or other purpose than the research study. We will only contact your General Practitioner to find out about the type of condition you have. We will provide your GP with the details of the closest research site and no further procedure will involve Alcon.

	Your Details aaaa
	First Name
	Last Name
	GP Details aaaa
	First Name
	Last Name
	Address of your GP aaaa
	Name or Number
	Address1
	Address2
	Town
	Postcode