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 products, or services related to the treatment of DMD;
  • Use the information I have provided for the provision of education, training, and ongoing support;Contact me
  • to obtain my feedback (for market research or other purposes) about the related services offered by
  • 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 any 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.