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Section 1

Patient authorization via signature is required in order to obtain services from Genentech
Access Solutions and the Genentech Patient Foundation. By signing this box, you agree to
the terms in the 'About Your Consent' section.

Person signing (if not patient)

Section 2

Financial Eligibility Information: Complete for Genentech Patient Foundation only
By completing this section, I am agreeing to the terms and conditions of the Genentech Patient Foundation outlined on page 1.

Sign and date here

Section 3

Patient consent to enroll in optional disease-specific education, support programs, market research and communication that may be considered marketing. I understand my PII may be needed for me to participate in these programs.

Sign and date here to choose to enroll

By providing my phone number and signing Box 3, I authorize Genentech to use auto-dialers or prerecorded and artificial voice to contact me. I understand that these calls/texts may mention the name of Genentech products or services, details about my insurance coverage and my doctor’s name. I understand that I am not required to consent to being contacted by phone or text message as a condition of any purchase of Genentech products or enrollment. Message and data rates may apply. I understand that I may opt out of receiving these communications at any time by calling (877) GENENTECH (877-436-3683).