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Consent Release

Forms for Patient Testimonials

CSID patients and caregivers and we at QOL Medical, LLC like to hear from other patients, parents, and patient caregivers about their experiences with Congenital Sucrase-Isomaltase Deficiency (CSID) and with Sucraid®. If you are interested in sharing your experiences and stories, we welcome you to do so. By submitting your or your child’s information, you agree that it will be governed by the Consent and Release statement below.

* Name:

* Patient Name:

* Caregiver Name:

* State of Residence:

How long have you or your child been using Sucraid®?

What does Sucraid® mean to you and your family?

How does Sucraid® help in managing symptoms of CSID?

If applicable, what have been your experiences with QOL Medical’s patient support programs for Sucraid®?

Are there any other aspects of your experiences with CSID and/or Sucraid® that you would like to share?

Consent and Release

I hereby grant QOL Medical, LLC, the maker of Sucraid®, permission to use my or my child’s first name and last initial, state of residence and patient testimonial (which may include some or all of the information inserted above) on www.sucraid.net. By signing this form, you are hereby consenting on your behalf and that of your child to allow QOL Medical, LLC to use and disclose the information in your or your child’s testimonial and acknowledge that your or your child’s testimonial may be distributed to the public. You or your child have the right to revoke this Consent and Release at any time by providing written notice of your revocation and submitting it to the Contact Person listed below. Please understand that revocation of this Release will not affect any action QOL took in reliance on this Release before receiving your or your child’s revocation.

I hereby authorize QOL Medical and staff to use my or my child’s testimonial and any information contained herein in its patient assistance or patient education programs, on its websites and in its public relations or other business efforts. I understand and approve the disclosure of my or my child’s testimonial information on its websites or other media and 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 or my child’s 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 or my child’s testimonial.

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

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

* Denotes required field

For questions or comments, please contact:
Brandi Rabon, MSW
CSID Patient Advocacy Consultant
brabon@qolmed.com
704-692-1634
4445 North Highway A1A, Suite 241
Vero Beach, FL 32963

QOL Medical, LLC

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