Physician Registration Form

By completing this form, you will be asked to disclose information about you, such as, your name, addresses, phone number(s), e-mail addresses and qualification. Your personal information will be used for the purpose of conducting the GILENYA Pregnancy Registry and drug safety. Your personal information will be collected and processed by IQVIA and by any company within the IQVIA group. Your personal information will be transferred to Novartis Pharma AG and any company within the Novartis group for reporting any drug safety issue to the health authorities, wherever located. All such recipients will be required to protect your personal information in accordance with applicable laws and regulations. However, the recipients may be located in countries that do not provide the same level of protection for your personal information as your country of residence, including the United States. You acknowledge that you have a right to access and modify any of the personal information that is held about you and to raise an objection in that regard by contacting your IQVIA contact at gpr@quintiles.com/gpr@IQVIA.com. IQVIA and Novartis will employ reasonable safeguards, including physical, electronic and administrative safeguards, to protect your personal information in their possession from loss, misuse, unauthorized access, disclosure, alteration, and destruction.

Please confirm that you have read and understood the above information. Please indicate your willingness to voluntarily complete and submit the form, by checking the box below.

By checking this box, I confirm that (1) I have read and understood the above information; (2) I am completing and submitting the form voluntarily; and (3) I consent to the uses and disclosures of my personal information as described above.

Physician Contact Information
First Name
Last Name
Type of health care professional (specialty)
Institution/Hospital Name
Address
Country
Phone Number
E-mail
Fax
Preferred Contact Method	Phone E-mail Fax
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