Programa de Pacientes Disfruto mi Salud
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Informed Consent

I, the undersigned participant of the Program according to the data included in this Regulation form (hereinafter the “interested person”)

I GIVE MY INFORMED CONSENT TO:

ASTRAZENECA CAMCAR COSTA RICA ANONYMOUS SOCIETY, with offices in San Rafael de Escazú, Plaza Roble Corporate Center, Los Balcones bulding, 3rd floor, legal entity identification number 3-101-504452 (hereinafter the “Responsible”)

To store my data included in this ticket, in the database in charge of the Responsible: “AZ Patient Program”, of wich I declare to know of its existence, in order to participate in the “Celebrate Life Program” (hereinafter “The program”), further authorizing being to be contacted by any means for the purposes of the program and other types of comercial prospecting communications.

I declare that I have been informed of the use and treatment that will be given to my data, that the primary recipient of this information will be responsible party himself, and this person may use treatment mangers, which I expressly consent to under the commitment of the responsible for draw up the relevant contracts with said third parties and that the data processing is guaranteed in accordance with national legislation, primarily that they will be processed by these third parties on behalf of and on behalf of the Responsible Party.

I declare that I have informed of the possibility that I have to exercise my rights to access, rectification, deletion and cancellation to the physical address of the responsible, or to the email address data customercare@celebratelifeprogram.com, that the responsible makes available for these purposes.

I also understand that the data requested in in this form is a mandatory response to participate in the Program, as well as that the sole consequence of not indicating such data or granting this consent will be the impossibility of including myself as a participant in the Program.