The Effectus Network Consent Form The Effectus Network allows our most trusted advisors to be notified first regarding opportunities to participate in research programs and surveys.By opting-in to the Effectus Network, you may be eligible to participate in (1) patient identification and consultation programs to help support clinical research studies, and/or (2) compensated exploratory research which consists of completing short surveys regarding your patient population (collectively, “program(s)”).Please review the points below and consider joining the Effectus Network. Your participation in any program is completely voluntary. You will be compensated at fair market value for your time and effort if you participate in a program. Compensation will vary depending on the program scope and requirements. Your personal information (provided below) will remain confidential. You may opt-out at any time. Your Personal Information: We collect and process your personal information to (1) notify you about program opportunities, and (2) pay your compensation should you participate in a program. If you are located outside the US, your personal information may be transferred to the US and disclosed to our US service providers. We will retain your personal information only for the time necessary to accomplish the purposes stated herein and to comply with applicable laws. We will not share or sell your personal information outside of Effectus. Question Title * CONSENT By checking this box and signing below, you opt-in and consent to join the Effectus Network on the terms set forth in this Consent Form. Your consent allows Effectus to contact you by email or phone about available programs, newsletters, and surveys for your consideration. You understand and agree that we have no obligation to select you for participation in a program. You have the right to revoke your consent at any time by notifying Effectus at optout@effectusctr.com or 89 Headquarters Plaza North, Suite #1450, Morristown, NJ 07960. Please allow 10 business days to process your opt-out request. By checking this box and signing below, you opt-in and consent to join the Effectus PI Preferred Network. You understand that you are allowing Effectus to share the personal data fields you provide below to a Study Sponsor for consideration as a Principal Investigator for a clinical trial. You understand and agree that Effectus and the Study Sponsor have no obligation to select you for participation in a study. You have the right to revoke your consent at any time by notifying Effectus at optout@effectusctr.com or 89 Headquarters Plaza North, Suite #1450, Morristown, NJ 07960. Please allow 10 business days to process your opt-out request. Question Title * If you opted-in to the Effectus Network, please provide the following information: Name: Degree: Specialty: Address: City: State: Zip: Email Address: Phone Number (Work): Phone Number (Mobile): Question Title * Date of completion: Please use the following format: MM/DD/YYYY Date Question Title * SIGN UP FOR TEXTS Check this box if you would like to receive texts from Effectus regarding opportunities to participate in programs outlined above. Privacy policy can be found on EffectusCTR.com. You may receive up to 4 messages a month. Message and data rates may apply. Reply STOP to end. By opting-in and completing this Consent Form, you consent to your personal information being processed by or on behalf of Effectus for the purposes set forth herein. Healthcare providers who reside in the state of Vermont are ineligible for participation. 89 Headquarters Plaza North, Suite #1450, Morristown, NJ 07960 | Phone: 973-753-2476 Done
