Information for X-Linked CGD Carriers

Program Eligibility

Date of Birth

You must be 18 years or older to complete enrollment online.

Please select your date of birth

Personal Information

First Name

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Last Name

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Address Line 1

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Address Line 2 (Optional)

City

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State

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ZIP Code

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Email This is not a valid email.

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Gender

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Mobile Phone This is not a valid mobile number.

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Patient Authorization and Consent

Step 1 of 2

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Consent to Health Data Collection & Processing for Marketing Purposes

I consent to Amgen collecting and processing my Health Data for the following purposes:

To conduct marketing activities, including market research activities, and to communicate with me regarding products and services that may be of interest to me.

Amgen uses the following for marketing purposes:

Health Data – my name, gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that Amgen is seeking my consent to collect and process my Health Data to market products and services to me and that I do not have to give consent to the collection and processing of my Health Data for marketing purposes in order to participate in the program. I also understand that Amgen will not sell my Health Data to third parties. If I consent to the collection and processing of my Health Data for marketing purposes, I agree that Amgen may contact me for marketing purposes. Finally, I understand that I may withdraw my consent to the collection and processing of my Health Data for marketing purposes at any time using one of the methods listed in the Additional Disclosures section below.

I consent to the collection and processing of my Health Data for marketing purposes
I do not consent to the collection and processing of my Health Data for marketing purposes

If you do not consent to the collection and processing of your health data for marketing purposes, you will not be able to receive marketing communications from Amgen. If you want to receive marketing communications from Amgen, select “I consent to the collection and processing of my Health Data for marketing purposes”

Step 2 of 2

*Please make a selection

Consent to Health Data Disclosure for Marketing Purposes

I consent to Amgen disclosing my Health Data to its data processors, contractors, and business partners for the following purposes:

To conduct marketing activities, including market research activities, and to communicate with me regarding products and services that may be of interest to me.

If I provide my consent, Amgen will disclose the following for such purposes:

Health Data – my name, gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that Amgen is seeking my consent to disclose my Health Data to its data processors, contractors, and business partners to market products and services to me and that I do not have to give consent to disclosure of my Health Data for marketing purposes in order to participate in . I also understand that Amgen will not sell my Health Data to third parties. Finally, I understand that I may withdraw my consent to the disclosure of my Health Data for marketing purposes at any time using one of the methods listed in the Additional Disclosures section below.

I consent to the disclosure of my Health Data for marketing purposes
I do not consent to the disclosure of my Health Data for marketing purposes

If you do not consent to the disclosure of your health data for marketing purposes, you will not be able to receive marketing communications from Amgen. If you want to receive marketing communications from Amgen, select “I consent to the disclosure of my Health Data for marketing purposes”

Additional Disclosures

I understand that participation in the Amgen® SupportPlus program and, if I have consented, receipt of marketing communications are optional services at no cost to me. The consent(s) above in no way affects my right to obtain any medications and I do not have to provide consent to be able to receive any medications. To obtain a copy of the consent(s) above or to withdraw my consent to collection, processing, and/or disclosure of my Health Data for any of the above purposes to which I have consented, I can contact Amgen by visiting www.amgen.com/DataSubjectRights. For more information about Amgen’s privacy practices, Amgen’s Privacy Statement can be found at http://www.amgen.com/privacy.

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