Me, the subscribed participant of The Program, or in its effect, the patient´s guardian or caregiver, according with the data included in the following registration form (The “Patient)
PROVIDE MY INFORMED CONSENT TO:
ASTRAZENECA CAMCAR COSTA RICA SOCIEDAD ANONIMA, with offices in San Rafael de Escazú, Roble Corporate Center, floor 5, bearer of corporate registration number 3-101-504452 (hereinafter referred to as the “Organizer”), to archive my data included in the following registration form, in the database of the “Organizer”: “AZ Patient Programs”, from which I declare know its existence, with the objective to participate in the program “Celebrate Life” (hereinafter referred to as the “Program”), additionally authorizing to be contacted by any means for Program initiatives and other type of related communications, with educational and/or commercial objective.
I manifest that I have been informed of the use and treatment that would be given to my data, that the primary destination of the information would for the “Organizer”, being allowed to use data managers, which I expressly consent, under the commitment of the “Organizer” to elaborate the required contracts with the third parties, and that the data is managed aligned to the conditions of this informed consent.
Regarding the services provided by professionals of the Patient Program “Celebrate Life” from AstraZeneca to the patient, in some occasions services would be offered remotely through tele conference or tele consult. The term “tele consult” refers to the form that would be used to interact with a patient using private virtual connection.
I declare that I have been informed of the following conditions to receive the services:
– The patient/caregiver accepts to receive the attention under this modality.
– The healthcare provider, as well as the patient are committed to prepare an adequate space for the session to be conducted privately, comfortably, and without interruptions.
– The starting and ending time of the consultation must be respected
– In case of an interruption of the session (Example: internet fails, interruption of the electric power), we would proceed as follows: If it is between the first 15 minutes of the session being scheduled. From 15-30 minutes from started the session, a new session would be coordinated according to the required time to finish the session. More than 30 minutes, the session would be considered as concluded, with the option to do an additional phone call if required.
– Conscious that the sessions or consults are done via internet, social media, or open connectivity, this has the inevitable possibility that the information of the session might get to an unauthorized third party, through robbery of the Information to any of the parties, by virus, or hackers. The professional from the “Organizer” coordinating the session would not have any responsibility of any kind with the patient, or other parties. Hence forth, the healthcare professional would be liberated of any responsibility, due to the detailed motives or for any other.
– If for any reason the data is revealed, and it is not associated with the professional or the patients will, the patient and the professional would be notified immediately.
– To ensure data protection, it is not allowed to record the sessions by any of the parties. The access to the confidential notes of the session is of exclusive use of the professional.
– The patient declares he/she has been informed of the possibility he/she has of exercising the right to access, rectify, suppress and cancel the address of the “Organizer”, or the email address firstname.lastname@example.org that the “Organizer” puts at the patients disposition.
– I also understand that the data requested in this formulary is of mandatory response to participate in the Program, and that the only consequence of not providing the data or providing consent, would be the denied possibility to participate on the Program.
Developed by AstraZeneca CAMCAR Costa Rica SA Roble Corporate Center, 5th floor, Escazú, San José, Costa Rica, telephone: (506) 2201 3400, postal code: 993-1260 Escazú.
www.camcar.astrazeneca.com for AstraZeneca CAMCAR SA To report adverse events, quality complaints or medical information, visit:
https://www.contactazmedical.astrazeneca.com. To access the product prescription information link: https://az.app.box.com/s/gsr9wy70k4sn8jg9qtbp2lrgzcqq77j7