Enrolment

* indicates the field is mandatory

Who is the ᴾᴿSPINRAZA™ (nusinersen injection) user?*

Myself

My child or child I legally care for

First name*

Last name*

Contact Details

Email*

Phone

Do not leave a message on this phone number

Child first name*

Child last name*

Child date of birth*

Date of birth*

Province

Biogen Canada Inc (3250 Bloor Street West, East Tower, Suite 1200, Toronto ON M8X 2X9) is responsible for the processing and safeguarding of your personal information obtained in this form. The information you enter will be reviewed by a Family Access Manager who will be in contact with you shortly to proceed with finalizing your enrolment for the SMA360 website. Partizan International Ltd. (31 Charlotte Road, London, EC2A 3PB, United Kingdom) and NavieGo Programs (Unit 1, 1393 North Service Rd. E, Oakville, ON L6H 1A7) are Biogen’s partners who will access your personal information. Partizan manages the website and NavieGo manages the Family Access Managers. This will involve a transfer of your personal information outside Canada, however Biogen has contracts in place with its partners to ensure your personal information is adequately protected. You can contact Biogen’s Data Privacy Officer for more information on the handling of your personal information, including your right to access and request correction of it, by contacting: privacy@biogen.com.

By ticking this box I consent to the collection, storage and use of the personal information entered onto this enrollment form by Biogen and Biogen’s partners. I understand that I am under no obligation to tick this box, however, without my consent, I will not be able to enroll into the SMA360 Patient Support Program. You may also later withdraw consent at ant time by contacting info@sma360.ca.

By ticking this box I consent to the collection, storage and use of the personal information entered onto this enrollment form by Biogen and Biogen’s partners. I understand that I am under no obligation to tick this box, however, without my consent, my child will not be able to enroll into the SMA360 Patient Support Program. You may also later withdraw consent at ant time by contacting info@sma360.ca.

Biogen-19407.