Congress Medical Information Request Form

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Please complete the fields below and then press the "submit" button to enter your information.

First Name *

Last Name *

Professional Designation *

Job Title/Department

Hospital/Company/Organization *

Address (Street, City, Province, Postal Code) *

Country *

Date *

YYYY

Work Phone *

Email Address *

Product Name *

Response Delivery Method *

Please state your question or request *

Would you like to be contacted by a Medical Science Liaison? *

Yes

REMINDER: Adverse Events and Product Complaints should NOT be reported using this form but MUST be reported within 1 business day at 1-877-TAKEDA-7 or pvsafetyamericas@takeda.com and/or Product Complaints at 1-877-TAKEDA-7 or PQC@takeda.com

By clicking submit, you confirm that your question/s was (were) not prompted or solicited by anyone in Takeda, and that the wording provided under the “Please state your request” section accurately states your question/s.

Please note that the personal data you provide on this form will be processed by Takeda to respond to your unsolicited request for medical information.

We may share your information with other Takeda affiliates and subsidiaries to fulfill your request. The sharing of your personal data may involve transfers to other countries. The data protection and privacy laws in these countries may not provide the same level of protection as your home country. Takeda will put in place safeguards to adequately protect your personal data in connection with such transfers.

Your personal data will only be used to respond to your request and will be kept for the time necessary to complete that response. You have the right to request access to rectification and deletion of your personal data or that its use be restricted. If you would like to exercise your individual rights, please contact us by accessing our Individual Rights webform at https://www.takeda.com/individualrights. If you have a question or complaint about how your personal data is being processed, you also have the right to contact Takeda's Privacy Office at privacyoffice@takeda.com or the Data Protection Supervisory Authority in your country. For more detailed information about how Takeda processes your personal data and your rights related to this processing please refer to Takeda’s Privacy Notice at https://www.takeda.com/privacy-notice/.

Copyright 2022 Takeda Pharmaceutical Company Limited. All rights reserved. Takeda and the Takeda Logo are registered trademarks of Takeda Pharmaceutical Company Limited.

VV-MEDMAT-62523 02/2022

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