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Consent to Use & Disclose Healthcare Professional Information
The personal information I have provided on this form is complete and accurate to the best of my knowledge. I will update my information promptly if any of the information changes.
I have voluntarily chosen to provide this personal information, including contact information. By providing this information, I am authorizing PTC Therapeutics, Inc. and its agents and contractors (“PTC Therapeutics”) to contact me about treatments, products, and services related to the treatment of Duchenne muscular distrophy (DMD), as well as to use and disclose the information for other purposes described below, using the contact information I have provided.
I authorize PTC Therapeutics to:
- Send me information or materials related to deflazacort or any other treatments, products, or services related to the treatment of DMD;
- Use the information I have provided for the provision of education, training, and ongoing support of the use of deflazacort;
- Contact me to obtain my feedback (for market research or other purposes) about deflazacort or any of the related services offered by PTC Therapeutics, including the support services provided by the deflazacort Information Center;
- Use the information I have provided for market research or other data purposes; and
- Contact me as otherwise required or permitted by law.
If at any time I do not wish to be contacted by PTC Therapeutics about or to receive any information related to deflazacort or any other treatment, product, or service related to the treatment of DMD or to be contacted for any of the other purposes described above, I understand that I may unsubscribe at any time.
By checking these boxes and clicking submit, you certify that you are a US Healthcare Professional and you are opting to receive information about DMD, EMFLAZA® (deflazacort) plus product information, site updates, educational information, patient support resources, and other information from PTC Therapeutics. You will be able to opt out of these communications at any time.