DEMENTIA ECOSYSTEM | PT Eisai Indonesia

Inquiry Form

Nama Dokter *

Rumah Sakit / Klinik *

Email *

No. Handphone *

+62

By ticking the box, I grant my consent to PT Eisai Indonesia to use my Confidential Information and Personal Data, such as Hospital Name, Person In Charge, Email and Phone Number for the purposes as stated in the Title. The Confidential Information and Personal Data will be kept for 10 years. For the avoidance of doubt, this consent is required and subject to the applicable laws of Indonesia.