INFORMED CONSENT for ACTEMRA UN-LICENSED INDICATION

Hospital RSUD Cengkareng hereby certify that:

The purchase order to PT Tempo for product Actemra, 2 vials (400mg) (as per
Purchase Order number XXXX as per-attached) is intended for the treatment of
hospitalized patient with severe COVID-19 pneumonia

Patient Initial(s) : Ny Cucu Kurnia

Treating Physician(s) : dr Benyamin spP

Hospital RSUD Cengkareng is fully aware that the usage of drugs as mentioned above
is for an unlicensed indication in Indonesia.

Hospital Authorized Person,

Name dr Benyamin spP

Title
Date 21 Jul 2021

[Roche is committed to the collection and management of safety information relating to

our products and we highly encourage healthcare professionals to report adverse
events, if any, to Roche Patient Safety Team at indonesia.safety@roche.com]