Consent and Release

Physician Testimonials Consent and Release

QOL Medical would like to hear from physicians who are prescribing Sucraid®(sacrosidase) Oral Solution for their patients diagnosed with Genetic Sucrase-Isomaltase Deficiency (GSID). If you are interested in sharing your experiences and stories, we welcome you to do so. By submitting your information, you agree that it will be governed by the Consent and Release statement below. PLEASE DO NOT PROVIDE ANY PERSONALLY-IDENTIFIABLE HEALTH INFORMATION OF ANY SPECIFIC PATIENTS.

Because these responses may be included as brief statements on a website, please try to be as concise and accurate as possible.

* Name:

* Title:

* State Where You Practice Medicine:

For how many patients have you prescribed Sucraid®?

What does Sucraid®mean to you and your patients?

How does Sucraid® help in managing symptoms of Genetic Sucrase-Isomaltase Deficiency? How effective has Sucraid® therapy been for your patients diagnosed with GSID?

If applicable, what have been your experiences and/or your patients’ experiences with QOL Medical’s patient support programs for Sucraid®, called SucraidASSIST™(Access and Support Services in Sucraid Therapy)?

I hereby grant QOL Medical, the maker of Sucraid®, permission to use my first name, last name, and title (i.e., John Smith, MD), state of medical practice, and physician testimonial (which may include some or all of the information inserted above) on

By signing this form, I am hereby consenting to allow QOL Medical to use and disclose the information in my testimonial and acknowledge that my testimonial may be distributed to the public. I have the right to revoke this Consent and Release at any time by providing written notice of my revocation and submitting it to the Contact Person listed below. I understand that revocation of this Release will not affect any action QOL Medical took in reliance on this Release before receiving my revocation and, if applicable, a reasonable time period to remove any portions of my testimonial from websites controlled by QOL Medical. QOL Medical shall not be required to retrieve any educational, patient assistance, promotional, or other materials or disclosures that contain portions or all of my testimonial that may have been disseminated, published or otherwise disseminated prior to any such revocation.

I hereby authorize QOL Medical and its staff to use my testimonial and any information contained herein in its patient assistance, patient education programs or promotional materials, on its websites, and in its public relations or other business efforts. I understand and approve the disclosure of all or any portion of my testimonial information on its websites or other media or to other individuals and entities that may be involved in the business, healthcare, or public relations efforts of QOL Medical.

QOL Medical may at its/their sole discretion make any and all changes in, additions to, and deletions from the testimonial including without limitation, cuts, edits, additions, changes, rearrangement, adaptation of the information to different formats, and other changes, additions, and deletions necessary to make the testimonial usable by QOL Medical. I understand and agree that the provided information may be used on, in, or in connection with any published materials and may be used, amended, transferred, displayed, broadcast, reproduced, and/or distributed publicly or otherwise, for any purposes whatsoever, including, but not limited to, educational, promotional, or commercial purposes.

I also release QOL Medical for any use of the provided information by third parties who intercept the materials or gain access to them over the Internet or other electronic media without QOL Medical’s permission, and for any claim of alteration, optical illusion or faulty mechanical reproduction, distortion, or illusion in reproduction. I understand that this Consent and Release does not obligate QOL Medical to use the provided information on, or in connection with, any materials.

I waive the right of prior approval and hereby release and hold harmless QOL Medical and its staff from any and all claims for damages of any kind based on the use of my testimonial, or information in the testimonial, or by virtue of this authorization. By signing below I agree and acknowledge that I have read and understood the above Consent and Release and agree to all terms described. I am of legal age, have read this Consent and Release, and freely sign this Consent and Release of my testimonial.

* By Checking this box, I am agreeing to the terms above.

* Please enter your full name in lieu of a signature.

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For questions or comments, please contact:
Brandi Rabon, MSW
CSID Patient Advocacy Consultant
[email protected]
4445 North Highway A1A, Suite 241
Vero Beach, FL 32963

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QOL Medical, LLC

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