MyCORE Enrollment Form

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Section A: Patient Particulars

Name of Patient (as per NRIC or Passport)

Nationality

NRIC Number

Passport Number

Date Of Birth

Contact No.

Email Address

Address of Patient

Street 1

Street 2

Street 3

City

Postcode

State

Country

Enrolment Information

Drug

Injector

Body Weight (kg) (only applicable for Saizen)

Section B: Caregiver Particulars

Caregiver Name

Caregiver Relationship With Patient

Contact No.

Email Address

Delivery Adress (If same from the above)

Street 1

Street 2

Street 3

City

Postcode

State

Country

Section C: Doctor Particulars

Name of Treating Doctor

Name of Hospital/Clinic

Address of the Hospital/Clinic

Street 1

Street 2

Street 3

City

Postcode

State

Country

Diagnosis(Please choose from the dropdown)

Diagnosis

Consent(Please check the following)

I hereby agree to receive disease management educational information via phone calls and SMS.

I hereby agree to participate in the face-to-face nurse support visit at my treating hospital. I am aware of the needs to notify program consultant at least 𝟱 𝗯𝘂𝘀𝗶𝗻𝗲𝘀𝘀 𝗱𝗮𝘆𝘀 prior to the appointment date. in the event of any rescheduling, I will need to notify program consultant at least 𝟮 𝗯𝘂𝘀𝗶𝗻𝗲𝘀𝘀 𝗱𝗮𝘆𝘀 prior to the appointment date and only up to one-time of rescheduling is allowed.

I prefer to have video call to substitute the face-to-face nurse support visit and I am aware of the needs to install Microsoft Teams on my gadget as the video conferencing platform to communicate to the nurse and the call will be recorded for quality and training purposes.

𝗠𝗲𝗿𝗰𝗸 𝗠𝘆𝗖𝗢𝗥𝗘 𝗣𝗮𝘁𝗶𝗲𝗻𝘁 𝗦𝘂𝗽𝗽𝗼𝗿𝘁 𝗣𝗿𝗼𝗴𝗿𝗮𝗺 (𝗠𝘆𝗖𝗢𝗥𝗘 𝗣𝗦𝗣) (𝗥𝗲𝗯𝗶𝗳®)

𝗜𝗻𝗳𝗼𝗿𝗺𝗮𝘁𝗶𝗼𝗻 𝗦𝗵𝗲𝗲𝘁 𝗮𝗻𝗱 𝗣𝗿𝗶𝘃𝗮𝗰𝘆 𝗡𝗼𝘁𝗶𝗰𝗲

Purpose & Background

This Information Sheet and Privacy Notice contains detailed information about the nature of the MyCORE Patient Support Program (“Program”), as initiative of Merck Sdn. Bhd (“Merck”) for patients suffering from Multiple Sclerosis. The purpose of this document is to explain to you in a clear and open manner (i) the nature of the support provided; and (ii) the steps and procedures involved to register your participation in the Program.

You are advised to read this document carefully and to feel free to reach out to your treating physician should you have any questions on the Program. We also encourage you to speak to friends, family members or local healthcare workers to help you decide on your participation in the Program.

Once you have read and understood the information contained in this document and decide that you would like to participate in this Program, please proceed to sign the enclosed Patient Enrolment Form. By signing the Patient Enrolment Form, you are indicating that you understand the information contained in this document and that you would like us to contact you using the personal information provided herein to confirm your participation in the Program.

You may keep this copy of the Information Sheet and Privacy Notice for your own personal records.

The Program

This Program has been developed to provide patients with the following support through the assistance by PatientCare Program Consultant of Zuellig Pharma Solutions Sdn. Bhd. (“Zuellig Pharma”) for:

(1) Training on how to use injectable devices and provide refresher training as required;

(2) Educating family and caregiver on the best ways to assist patients;

(3) Providing information for patients on their Rebif® treatment;

(4) Providing information and support on how to manage common side effects and reporting side effects to the PatientCare Program Consultant and your treating physician;

(5) Providing an additional means of communication to the patient’s treating physician by providing them with reports and updates on the patient’s health status.

(6) Supply device and consumable (ie needles and battery) to patients and as point of contact to request for a replacement device/replenishment of consumables/collection of faulty/unused device.

Patients who participate in this Program will be able to enjoy the program benefit and thus to permit PatientCare Program Consultant to visit them at treating hospital during their next medical appointment and contacting them for educational support. It is our hope and desire that the Program will help to improve the quality of life of patients.

𝗠𝗲𝗿𝗰𝗸 𝗠𝘆𝗖𝗢𝗥𝗘 𝗣𝗮𝘁𝗶𝗲𝗻𝘁 𝗦𝘂𝗽𝗽𝗼𝗿𝘁 𝗣𝗿𝗼𝗴𝗿𝗮𝗺 (𝗠𝘆𝗖𝗢𝗥𝗘 𝗣𝗦𝗣) (𝗦𝗮𝗶𝘇𝗲𝗻®)

𝗜𝗻𝗳𝗼𝗿𝗺𝗮𝘁𝗶𝗼𝗻 𝗦𝗵𝗲𝗲𝘁 𝗮𝗻𝗱 𝗣𝗿𝗶𝘃𝗮𝗰𝘆 𝗡𝗼𝘁𝗶𝗰𝗲

Purpose & Background

This Information Sheet and Privacy Notice contains detailed information about the nature of the MyCORE Patient Support Program (“Program”), as initiative of Merck Sdn. Bhd (“Merck”) for patients suffering from Growth Hormones Deficiency, Turner Syndrome or Small Gestational Age. The purpose of this document is to explain to you in a clear and open manner (i) the nature of the support provided; and (ii) the steps and procedures involved to register your participation in the Program.

You may keep this copy of the Information Sheet and Privacy Notice for your own personal records.

The Program

(1) Training on how to use injectable devices and provide refresher training as required;

(2) Educating family and caregiver on the best ways to assist patients;

(3) Providing information for patients on their Saizen® treatment;

(4) Providing information and support on how to manage common side effects and reporting side effects to the PatientCare Program Consultant and your treating physician;

(5) Providing an additional means of communication to the patient’s treating physician by providing them with reports and updates on the patient’s health status.

(6) Supply device and consumable (ie needles and battery) to patients and as point of contact to request for a replacement device/replenishment of consumables/collection of faulty/unused device.

Patients who participate in the Program will be able to enjoy the program benefit and thus to permit PatientCare Program Consultant to visit them at treating hospital during their next medical appointment and contacting them for educational support. It is our hope and desire that the Program will help to improve the quality of life of patients.

Privacy Notice

(1) What is the Merck MyCORE Patient Support Program and what is the purpose: The Merck MyCORE Patient Support Program (“Program”) is aimed at providing educational support in the manner and for the purposes set out in the Information Sheet on page 2.

(2) What data is collected: The data collected shall include information enclosed in the Patient Enrolment Form.

(3) What is the intended purpose of use of the data collected and who will access: The data collected is intended to provide the PatientCare Program Consultants or Zuellig Pharma affiliates or any designated service providers with patient’s medical history and personal information so that they will be able support to patient’s needs, report adverse events and to facilitate feedback from the patient to the Treating Physician Doctor regarding the progression and treatment of patient’s disease. The data collected will also be used for the purpose of determining my eligibility and for enrolling me into this Program as well as for the management of this Program.

(4) Transfer and storage of data: Patient’sdata will be stored in a centralised database located outside of Malaysia and operated by Merck. Merck, other Merck companies and its service providers may access the data for providing the maintenance, operation or administration of data, the software or database. The access may also take place from outside the Malaysia; Merck Sdn. Bhd. will take all steps reasonably necessary to ensure that the data patient provide is adequately protected according to the requirements of the data protection laws of Malaysia.

(5) Right to access, rectification and objection: Patients have the right to access their data, to have the same rectified or updated and to object to the processing of patients’ data, in accordance with the Personal Data Protection Act 2010, by emailing to MYCore@zuelligpharma.com or contactings Zuellig Pharma at +603 2027 4631.

(6) Voluntary participation and right to withdraw: Participation in this Program is completely voluntary. Patient will not receive any payment for the participation in this Program nor will be required to pay for participating in this Program. Patient has the right to stop participating in this Program and to revoke the consent to the processing of the data, at any time by submitting a written request and emailing to MYCore@zuelligpharma.com or contacting Zuellig Pharma s at +603 2027 4631. Revoking my consent will automatically result in my withdrawal from this Program and any of its benefits.

(7) Additional Information: If you have any problems, questions or suggestions regarding the collection of data or would like to provide feedback on the Program, please feel free to contact Zuellig Pharma as follows:

Attention :	MyCORE Patient Support Program Consultant
Address :	MyCORE c/o Zuellig Pharma Solutions Sdn. Bhd., No. 15, Persiaran Pasak Bumi Seksyen U8, Perindustrian Bukit Jelutong, 40150 Shah Alam, Selangor Darul Ehsan, Malaysia.
Telephone :	+603 2027 4631
Fax :	+603 7840 0397
Email :	MYCore@zuelligpharma.com