EmailMeForm
California Residents - Authorized Agent
If you are an authorized agent making an access or deletion request on behalf of a California consumer, please provide the information below so that we may process the request. To submit a request by phone, you may also call 1-866-735-4137 extension 3. Please note that we will communicate with the consumer at the consumer’s contact email address you provide in order to conduct certain verification procedures directly with the consumer.
If you are making this request for yourself, please do not use this form. Instead, please visit
here
to submit your request.
NOTE: An asterisk "*" indicates a required field
Agent's Name
*
First
Middle
Last
Please complete all fields:
Agent's Zip Code
*
Agent's Email Address
*
Are you submitting this request on behalf of a California consumer?
*
Yes
No
Business entity agents only: Is your registration with the California Secretary of State active?
*
Yes
No
If yes, please provide your California registration number
*
Is the consumer currently or has the consumer ever been a member of ASPIRE Galderma Rewards?
*
Yes
No
Please select one or more from the list below.
*
The consumer would like to know the categories of personal information Galderma may have collected.
The consumer would like to know the specific pieces of personal information Galderma may have collected.
The consumer would like Galderma to delete personal information that it may have about the consumer.
The consumer would like to opt out of the sale of personal information that Galderma may have collected about the consumer.
Consumer's Name
*
First
Middle
Last
Please complete all fields:
Consumer's contact email address
*
Email associated with consumer, which was used when interacting with Galderma
*
What Galderma websites have you interacted with? Please select one or more from the list.
*
Galderma.com/us
Acne.com
Cetaphil.com/us
Differin.com
Dysportusa.com
Epiduoforte.com
Epsolay.com
Galdermacc.com
Mirvaso.com
Oracea.com
Restylaneusa.com
Rosacearelief.com
Sculptrausa.com
Soolantra.com
Triluma.com
Twyneo.com
Other
* Please use the tool below to upload the following documentation:
• Written Permission: Written permission signed by the consumer demonstrating you have been authorized by the consumer to make this request. This written permission must include the consumer’s name, email address, and authorization for you to act on the consumer’s behalf in making the request.
• For business entity authorized agents only: Certificate of Status issued by the California Secretary of State.
