PATIENT CONSENT TO THE COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

The Sun360™ Patient Support Program is sponsored and offered by Sun Pharma Canada Inc. (“SUN PHARMA”) in order to support patients who are taking certain SUN PHARMA products (the “Program”). The Program is administered by SUN PHARMA and a third-party service provider and their agents and affiliates (collectively, “Program Administrators”).

I understand the services offered by the Program Administrators. My physician has explained the purpose and expected benefit of the prescribed medication. I authorize my physician to disclose my personal health information for the Sun360™ Patient Support Program and prescription to the Program Administrators and its authorized representatives. I authorize the collection, use and disclosure of my personal information. I grant the Program Administrators the right and permission to use and disclose to its affiliates (as defined under the Ontario Corporation Act) or other third-party service providers, as needed for various purposes, including but not limited to helping the Program Administrators assess and improve patient assistance programs and how it provides services to patients, additional personal information about myself in aggregated (combined with other data) or de-identified form (personally identifiable information removed), such as information regarding my health outcome, my demographics and the name and contact information of my healthcare providers such as my treating physician (the “Additional Information”). Additional Information in aggregated or de-identified form may also be used to perform activities such as, including but not limited to, data assessment and data analytics for the purposes of, amongst other initiatives, optimizing service offerings to patients and other third parties, as well as the commercialization of such offerings. The Program Administrators and their third-party service providers are contractually obliged to strict data protection and security requirements. Only relevant personnel will have access to my Additional Information.

I understand that the Program Administrators and their service providers may store or process my personal information outside of Canada (including the United States), where local laws may require the disclosure of personal information under circumstances that differ to those that apply in Canada. Also, my personal information may be used or disclosed to third parties when permitted or required by applicable laws, court orders or government regulations.

Also, any additional information about the Program Administrators’ privacy policies and practices is available at https://www.mckesson.ca/web/mckesson-canada-extranet/privacy.

I understand that I may arrange to access the personal information held by the Program Administrators and may rectify any deficient information, by contacting the Program Administrators in writing at 2300 Meadowvale Blvd, Mississauga, ON L5N 5P9. I understand that I may revoke this consent at any time by writing to the Program Administrators at the address above.

I understand that SUN PHARMA may appoint a new Program Administrator at any time and I consent to the continued collection, use and disclosure of my information by the new Program Administrator as set out on this form.