7 cast MEMBERSHIP FORM Pfizer Sulit Card No. Date | | mm dd y This membership form is for the Pfizer Sulit Patient Care Program. Please print and fillout the details completely. You may send the form through email, and fax to continue with your FREE membership, health support benefits like health education materials, reminders and special price rate, among others. Email: Pfizerclub @ pfizer.com Fax: Metro Manila 672 2000 Provincial Toll free 1800 10 672 2000 Please attach 1 copy of any Government Issued ID Name Birth date Sex Male Address lage l Municipal City Province Zip Code Contact Details: Mobile Phone Number: Home/Office Phone Number: Email Address: IMPORTANT: Your doctor's details below should coincide with your prescription: | am aware of the Terms and Condition of the Pfizer Sulit Patient Care Program (“the Program”) and the mechanics thereof and hereby recommended my patient for membership in the program. Doctor's Name Signature By signing, | certify that the information given is true and correct. My enrollment and /or use of the Sulit card shall be deemed my acceptance and agreement with the terms and conditions of the Pfizer Sulit Patient Care Program as specified in this membership form or Pfizer Sulit Patient Care website. SS PP-PCP-PHL-0193 Member's signature Production Date: March 2018 oer, Inc, 1/F-20/F 8 Rockwell Bulging, Rockwell Center Hidalgo Drive, Poblacion, Makati Citytse ered Pfizer Sulit Patient Care Program Terms and Conditions Updated as of October 26, 2017 1. The Pfizer Sulit Patient Care Program (PSPCP) is a disease management and patient adherence program which provides members with adherence support which may include patient educational materials, reminders, access support to the prescribed medicine, access to the Pfizer Healthline and member-only pages at www.Pfizersulitcare.com.ph and added support from Health Support Partners. Benefits may change at any time. 2. Enrollment of the patient in the program by the doctor is required. Enrollment takes place upon discretion of the doctor by issuing a Pfizer Sulit Card (CARD) with card carrier and/or other materials to patient. Enrollment could take place only after patient consults doctor about a particular ailment, after doctor diagnoses the patient, and after doctor opts to prescribe the product as treatment. 3. To complete membership and to activate the Pfizer Sulit Card (CARD) after enrollment, patient needs to text his/her first name, last name, and CARD number to Pfizer. Depending on mobile service provider, text charges apply. Patient also needs to agree through text to these PSPCP Terms and Conditions, including processing of personal information in Section 13, and to confirm that patient’s doctor has enrolled him/her to this program. The CARD can be used at participating partner drugstores of the PSPCP. It is not transferable. The member must present a valid doctor’s prescription together with the CARD. 4, By completing membership to the program, and/or by using and continued use of the CARD, the holder agrees to be bound by PSPCP Terms and Conditions as appearing in the card carrier or, as far as they are applicable, as published in http://www.Pfizersulitcare.com.ph/. 5. Access support to the prescribed medicine is through the special program price rate for the participating medicine the member is prescribed with, and other health support benefits such as, health reminders and information through SMS, eNewsletters, and member-only pages at www.pfizersu- litcare.com.ph which can be availed with the use of the CARD. 6. A patient is entitled to one CARD per medicine. Thus, a patient can only have one CARD per medicine at a given time. 7. The CARD is automatically assigned a specific quantity that can be purchased per month. The quantity will depend on the type of medicine. If less than the specific amount is consumed on a particular month, the balance shall be forfeited and at no instance will it be carried over to the following month. At the start of each month, the number is reset and the CARD is again automatically assigned the specific quantity applicable for the current month. Some CARDS, depending on the product participating in the program, have fixed expiry dates. All CARDS will expire if not used in two (2) years from registration; or five (5) years from last use. 8. The special program price rate to be availed of by patients shall be based on the suggested retail price of the medicine. Actual retail prices of drugstores may vary. The special program price rate may change at any time. 9. The special program price rate is valid for cash or credit card purchases, except for Health Support Partner offers which are subject to separate mechanics and validity dates. 10. This CARD is issued by Pfizer, Inc. and remains to be its property. In case of loss, the card is meant to be returned to: Pfizer, Inc. 18F-20F 8 Rockwell Building, Hidalgo Drive, Rockwell Center Makati City, Philippines 11. For any claims related to CARD benefits, patients must be able to present the Official Receipt issued by the drugstore where the product was purchased.12. By having accepted the terms and conditions of the PSPCP, the patient understands and acknowledges that the information disclosed and obtained in the course of the PSPCP, which includes personal information, are collected, processed and stored in an automated Pfizer-managed member data base system and/or in the member data base system of its affiliates or authorized third parties, and which shall be used and administered solely by Pfizer, and its said affiliate companies and authorized third parties in connec- tion with the implementation and enhancements of the PSPCP, including the monitoring of the frequency of use and quantity of purchases made by the Cardholder. The patient gives his/her consent to Pfizer’s and its directors, officers, employees, advisers, agents and representatives’ (a) collection, processing, storage and use of personal information; and (b) outsourcing of the collection, processing, storage and use of personal information to service providers whether within or outside the Philippines. The foregoing constitute the express consent of the patient under the applicable confidentiality and data privacy law of the Philippines and other jurisdictions, and agree to hold Pfizer and relevant parties free and harmless from any and all liabilities, claims, damages and suits of whatever kind and nature that may arise in connection with the implementation and compliance with the authorization conferred by the patient hereunder. The foregoing consent shall continue for the duration of and shall survive the termination of the use of the card. The foregoing is without prejudice to the patient’s rights to reasonable access to, upon demand, and correction of his personal information, as well as his right to lodge a complaint before the National Privacy Commission, under Section 16 of the Data Privacy Act. The patient likewise agrees that the information referred to in this section may be disclosed to the patient’s attending physician and to any of Pfizer-authorized affiliates and third parties for any purposes that may include monitoring and following—up on the patient’s compliance with his physician’s prescription as well as improving PSPCP. For these purposes, Pfizer and its authorized affiliates shall store personal information on the patient, as defined under Section 3 (g) of the Data Privacy Act, within five (5) years from the last use of the Pfizer Sulit Card. 13. Any patient-specific information may not be used in any form of publica- tion or promotional material without prior written approval by the patient. De-identified and aggregate patient data may be analyzed and used to provide basis to further improve the program. 14, By availing of the benefits granted by the program, the member consents to receiving mail, e-mail, calls, text messages and/or other means of commu- nication from Pfizer and its affiliate companies on healthcare and PSPCP-re- lated topics which by applicable regulations, they may refuse or decline at any time. 15, Pfizer and its affiliate companies shall not be responsible nor liable to the patient-member for any loss or damage incurred or suffered as a consequence of: (a) any malfunction, defect or error in any machine or system of authorization whether belonging to or operated by Pfizer or its Drugstore-partners; (b) any delay or inability of Pfizer to perform any of its obligations pursuant to these terms and conditions due to any mechanical, data processing, or telecommunication failure, act of God, civil disturbance, or any event outside Pfizer, Inc.’s control or as a consequence of any fraud or forgery; and/or (c) any damage to or loss of or inability to retrieve any data or information that may be stored in any Card or any device whatsoever. 16. To the extent allowed by law and applicable regulations, Pfizer and its affiliate companies shall verify the identity of prescribing doctors indicated in the form. In the event that a prescribing doctor or the information relating to the prescribing doctor is found to be fictitious or false, Pfizer reserves the right to cancel the patient's membership to PSPCP, including all its benefits. 17, The benefits to the program may be availed of for the duration that Pfizer offers the same. Pfizer may opt to stop or continue the program, in full or in part, at any time at its own discretion. Pfizer also reserves the right to change the program, its mechanics and benefits, and these terms and conditions, in full or in part, any time.