CONSENT TO USE & DISCLOSE PATIENT/CAREGIVER INFORMATION

The personal information I have provided on this form is complete and accurate to the best of my knowledge.

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 dystrophy (DMD), as well as to use and disclose the information for other purposes described below, using the contact information I have provided. I understand and agree that PTC Therapeutics may leave messages for me that disclose that someone has DMD or takes specific medication or that a specific medication used to treat DMD is available.

I authorize PTC Therapeutics to:

  • Send me information or materials related to any and all treatments, products, or services related to the treatment of DMD;
  • Contact me to obtain my feedback (for market research or other purposes) about any of the products or services offered by PTC Therapeutics, including the support services provided by the PTC Cares™ 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 treatments, 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.