SAMSUNG BIOEPIS

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Name
Birth date
Gender	Male Female
E-mail address
Country
Company name/ Organization
Occupation
HCPDuplicate check not possible Physician Pharmacist Nurse Other	Non-HCPDuplicate check not possible Patient Customer Caregiver Family Other
Phone number
Product name
Type of inquiry Duplicate check possible	Medical information Adverse Event Product quality complaint
Subject
Message

Consent Form for collection and use of personal information

1. The Personal Information Collected and the Purpose of Collection and Use
I hereby grant Samsung Bioepis Co., Ltd. ("Bioepis") the authority to collect, record, store, process, dispose, disclose, and use my personal data for the following purpose(s) for the following retention period.

개인정보 제공
Classification	Personal Information	The Purpose of Collection and Use	Retention period
Required	Email address, Name	Answering and processing your inquiry (if necessary)	For the period necessary to fulfill the purpose of collection and usage *
Optional	Company name, Occupation, Phone number	Answering and processing your inquiry (if necessary)

*Yet, when certain data is required to be preserved by other laws, it is secured for such period that the law demands.

2. Transferring Personal Information to Third Parties
I give explicit consent for my personal data to be transferred to the following recipients.

개인정보 제공
Recipient	Personal Information	The Purpose of Transfer	Retention period
Partners of the Company (IQVIA, Biogen, Organon, Yuhan, Boryung Pharmaceutical and so on)	Email address, Company name, Name, Occupation, Phone number	Answering and processing your inquiry	For the period necessary to fulfill the purpose of transfer*

*Yet, when certain data is required to be preserved by other laws, it is secured for such period that the law demands.

I am aware that I can withdraw your permissions initially given at any moment.

I have read and understood the Privacy Notice, which is published on the Bioepis' homepage

Agree Disagree

This inquiry can be made only to those who are 16 years of age or older.
Are you over the age of 16?

Yes No

When entering personal and sensitive information, a third party must not act on their behalf, and the information subject
must enter it directly.
Are you the information subject?

Yes No

If a third party inquires and enters personal and sensitive information on behalf of the information subject, the third party must obtain the signature of the information subject in the extra consent form attached below, and attach the consent form to the inquiry. However, if the consent form is not attached, there may be restrictions on responses

Consent Form Third Party Inquiry Download

Please upload the downloaded consent form below.

upload

Please read the following and check the box to confirm your consent.

1. I hereby grant Samsung Bioepis Co., Ltd. ("Bioepis") the authority to collect, record, store, process, transfer, dispose, disclose, and use
(collectively, "ProCess") my personal data for the following purpose(s) as long as the related Samsung Bioepis' product is authorised and for at least 10 years after the marketing authorisation has ceased to exist, provided that if additionally required by the local laws and regulations, it may be stored accordingly:
for the purpose of responding to medical inquiries, pharmacovigilance activities and product quality complaint in compliance with legal obligations.

2. a. I give explicit consent for my personal data below to be processed for the purposes specified in paragraph 1.

Categories of personal data: Name, institution, region, job, age, sex, contact details, inquiry

b.I give explicit consent for my sensitive personal data below to be Processed for the purposes specified in paragraph 1.

Categories of sensitive personal data:
Medical history and health-related data, personal and medical inrformation of the individual experiencing adverse event(s) for Samsung Bioepis' biopharmaceutical products

3. I give explicit consent for my personal and sensitive data to be transferred to a recipient (Health authorities in respond to regulatory requiredrequests/Samsung Bioepis' Business Partners such as Biogen, Organon, and etc./Samsung Bioepis' third parties including PrimeVigilance, IQVIA, and ArisGlobal KK for the purpose of drug safety responsibilities) and processed outside the European Economic Area ("EEA"), which may not provide a level of data protection equivalent to the one provided within the EEA, and the Country may have no adequacy decision by the European Commission.

4. I am aware that I can withdraw my permissions intially given at any moment.

5. I have read and understood the Privacy Notice, which is published on the Bioepis' homepage (https://www.samsungbioepis.com/en/tetc/notice.do)

By clicking this checkbox, I acknowledge that I have read and understood this Informed Consent Form and the Privacy Notice, and consent to this Informed Consent Form.

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