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By submitting this form, I acknowledge all information I provided may be used by LEO Pharma Inc., its collaborators, affiliates and contracted service providers (collectively “LEO”) to provide me with additional information about products or services.

Once my health information has been disclosed to LEO, I understand that federal privacy laws may not protect it from further disclosure. However, LEO agrees to protect my health information by using and disclosing it only for the purposes allowed by me in this authorization or as otherwise allowed by law and will not sell or rent my information to any unauthorized parties or mailing lists.

I authorize LEO to contact me by mail, telephone, SMS text, or email with information about atopic dermatitis and products, promotions, services and research studies, and to ask my opinion about such information and topics, including market research and disease-related surveys.

I further authorize LEO to de-identify my health information and use it in performing research, education, business analytics, marketing studies or for other commercial purposes. I understand that different LEO parties may share identifiable health information with one another in order to deidentify it for these purposes and as needed to perform the Services or to send the communications listed above (the “Communications”).

I understand that I do not have to provide this information or receive the Communications, and that doing so will not affect my medical treatment, or access to health benefits or LEO medications. I may opt out of receiving Communications at any time by notifying a representative by calling 1-877-494-4536 or by sending a letter to LEO 7 Giralda Farms – 2nd Floor, Madison NJ 07940 USA.

Questions or comments? Contact LEO US or call 1-877-494-4536

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