Data collection System | Philippines Paxlovid Patient Data Collection System

I’m a patient

I’m a representative / caregiver

I acknowledge that processing my personal information and my sensitive personal information (collectively the “Information”) is necessary in compliance to Philippine Food and Drug Administration’s requirement to track and trace adverse events of patients, and for protecting my life and health. Furthermore, I agree to sign-up and register in the Paxlovid Patient Data Collection System (DCS) for these purposes, to have my Information processed, as defined under the Philippine Data Privacy Act of 2012 (the “DPA”). I understand that processing, as defined by the DPA, shall include, among others, sharing of my Information with relevant government offices, and with vendors, providers, advisers, and affiliates of Pfizer, Inc. for the said purpose; sharing of my Information, and storing the same in and / or out of the Philippines; maintaining of my Information whether in and / or out of the Philippines for purposes of documenting adverse events.

By signing up and registering in the Paxlovid Patient DCS, I understand and acknowledge that I will be disclosing Information which would be collected, processed and stored in an automated Pfizer-managed data base system and/or in the data base system of its affiliates or authorized third parties, and which shall be used and administered solely by Pfizer, and said affiliate companies and authorized third parties in connection with the implementation and enhancements of this DCS. I give my consent to Pfizer and its directors, officers, employees, advisers, agents and representatives’ (a) collection, processing, storage, and use of my Information, whether within or outside of the Philippines; and (b) outsourcing of the collection, processing, storage and use of my Information to service providers whether within or outside the Philippines; and (c) storage, maintenance, and otherwise use my Information for such period and for the purpose of allowing Pfizer to comply with its obligations relative to safety and / or adverse events monitoring and / or reporting, whether pursuant to its internal policies or to its legal obligations whether within or outside of the Philippines. The foregoing constitute my express consent 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 I confer hereunder. The foregoing is without prejudice to my rights to reasonable access to, upon demand, and correction of my Information, as well as my right to lodge a complaint before the National Privacy Commission, under Section 16 of the DPA.

I likewise agree that the Information referred to in this section may be disclosed to any of Pfizer-authorized affiliates and third parties for any purposes that may include implementation and improvement of the Paxlovid Patient DCS. For these purposes, Pfizer and its authorized affiliates or authorized third parties shall store my Information (as above provided) for the duration of the registration of the Patient and use of this digital resource.

By providing my mobile number and/or email address, I hereby confirm and provide consent for Pfizer, its employees and/or affiliates, or authorized third parties to send notifications on Pfizer product updates, and contact me through the same.

Patient’s name or initials

E-mail address

Mobile or landline number

Mobile

Landline

Purchase location

Lot number

In compliance to Philippine Food and Drug Administration’s requirement to track and trace adverse events of patients, and on behalf of the patient, I am registering the patient subject of this online enrollment in the Paxlovid Patient Data Collection System (DCS) (the “Patient”), and providing his / her personal information and sensitive personal information (collectively the “Information”) for processing, as defined under the Philippine Privacy Act of 2012 (the “DPA”) for the purposes of compliance with the said requirement of the Philippine Food and Drug Administration, and for protecting his / her life and health. In this regard, I expressly confirm and warrant that I am the authorized representative / caregiver of the Patient for his / her treatment for COVID-19, as well as for the processing of the Patient’s Information. I understand that processing, as defined by the DPA, shall include, among others, sharing of the Patient’s Information with relevant government offices, and with vendors, providers, advisers, and affiliates of Pfizer, Inc. for the said purposes; sharing of the Patient’s Information, and storing the same in and / or out of the Philippines; maintaining the Patient’s Information whether in and / or out of the Philippines for purposes of documenting adverse events.

Moreover, by signing up and registering in the Paxlovid Patient DCS, I understand and acknowledge that I may be disclosing Information of the Patient and / or my own. which would be collected, processed and stored in an automated Pfizer-managed data base system and/or in the data base system of its affiliates or authorized third parties, and which shall be used and administered solely by Pfizer, and said affiliate companies and authorized third parties in connection with the implementation and enhancements of this DCS. I give my consent to Pfizer, on my own behalf and on behalf of the Patient in my care, and its directors, officers, employees, advisers, agents and representatives’ (a) collection, processing, storage and use of my Information; and (b) outsourcing of the collection, processing, storage and use of my Information to service providers whether within or outside the Philippines; and (c) storage, maintenance, and otherwise use of my and the Patient’s Information for such period and for the purpose of allowing Pfizer to comply with its obligations relative to safety and / or adverse events monitoring and / or reporting, whether pursuant to its internal policies and / or to its legal obligations whether within or outside of the Philippines. My continuing to submit the form into the Paxlovid Patient DCS constitutes my express consent, for my own and on behalf of the Patient in my care, under the applicable confidentiality and data privacy laws 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 I confer hereunder. The foregoing is without prejudice to my and / or the Patient’s rights to reasonable access to, upon demand, and correction of my or of the Patient’s Information, as well as my or the Patient’s right to lodge a complaint before the National Privacy Commission, under Section 16 of the DPA.

I likewise agree that my and / or the Patient’s Information referred to in this section may be disclosed to any of Pfizer-authorized affiliates and third parties for any purposes that may include implementation and improvement of the Paxlovid Patient DCS. For these purposes, Pfizer and its authorized affiliates or authorized third parties shall store my Information for the duration of the registration of the Patient and use of this digital resource.

By providing my mobile number and/or email address, I hereby confirm and provide consent for Pfizer, its employees and/or affiliates, or authorized third parties to contact me in connection with any Information that I have submitted through the Paxlovid Patient DCS, and with any adverse event that I may report.

Name of representative/caregiver

Patient’s name or initials

Patient’s or representative’s E-mail address

Patient’s or representative’s mobile or landline number

Mobile

Landline

Purchase location

Lot number