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*Required field.
SECTION A:
To be completed by all applicants
† Required for students only.
Your mobile phone number will be used to contact you after graduation to update your contact information.
Would you like to receive text messages from the Allergan® OPTOMETRY JUMPSTART® program?
Examples of texts include messages regarding the status of product sample shipments, appointment scheduling, and other resources. Consent to receive texts is not required as part of the OPTOMETRY JUMPSTART® program.
† The frequency of these messages depends on user preferences/activity, and message and data rates may apply. You can unsubscribe at any time by texting "STOP".
SECTION B:
Please complete all of the known fields below.
To be completed by fourth-year students and graduates only
Are you, or will you be, employed by any of the following in the next 12 months?
SECTION C:
The categories of personal information collected in this form include contact information, optometry school, graduation year, and employment. The personal information collected will be used for enrollment and participation into the OPTOMETRY JUMPSTART® program and to perform research and analytics. For more information about the categories of personal information about you that may be collected by AbbVie and the purposes for which AbbVie may use personal information about you, visit https://privacy.abbvie.
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Form Name:
Form Category:
Account Management, Contact, Interactions, Quiz, Registration, Services
Form Sub-Category:
Password Resets, Login, Profile, Representative, Contact Us, Polls, Social Share, Doctor Discussion Guide, Dosing Guide, Symptom Checker, Knowledge Assessment, Event, More Info, Sign Up, Saving Card, Benefit Verification, Benefit Enrollments, Medical Exception, Injection Form, Share a Story
Form MVA Name:
Form MVA Type:
Download, Form, Link, Share, Tool, Video
Form MVA Tier:
Form MVA Category:
Savings Card, Insurance, Symptom Journal, Test Score Tracker, Condition Information, Doctor Discussion Guide, Dosing Information, Enrollment Form, Flashcard, Medical Exception, Patient Counseling Guide, Savings Card, Symptom Journal, Doctor Discussion Guide, Doctor Search, Dosage Calculator, Enroll, Med Reminders, Quick Poll, Resource Request, Symptom Quiz, UGC Submission, Contact Rep, Savings Card, Social Share, App Store, More Info, Patient Resources, Share Information, Share Results, Submit a Story, Assessment Tool, Benefits Verification, Carousel, Initiation, Myth versus Fact, Workaround Quiz, Formulary Tool, Image Expand, Medical Exception, Q And A, Slider, Administration Instructions, Condition Information, Insurance, Inventory, Mechanism of Action, Patient Story, Product Overview, Program Overview, Injection Training, Other
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