INFORMED CONSENT For ACTEMRA UN-LICENSED INDICATION

Hospital Muhammadiyah Lamongan hereby certify that : the purchase order to

PT Tempo for product actemra 400 mg inj. 2 vials is intended for the treatment
of hospitalized COVID-19 patients.

Patient Initial(s) : Mr. Hamdan Azahari

Treating Physician(s) : dr. Anas Machfud, Sp.An.

Hospital Muhammadiyah Lamongan is fully aware that the usage of drugs as

mentioned above is for an unlicensed indication in Indonesia.

Hospital Authorized Person

dr. Anas Machfudz, Sp.An.

Date 2nd July 2021