Consumer Request

I am submitting this request *

For myself (i.e., I am the “consumer”)

On behalf of another consumer (i.e., I am the “requestor”)

Consumer’s First name *

Consumer’s Last name *

Consumer’s E-mail address *

Consumer’s Country of Residence *

Consumer’s State of Residence *

Consumer’s Company Name

Consumer’s Phone Number

Requestor’s First name *

Requestor’s Last name *

Requestor’s relationship to Consumer *

Requestor’s E-mail address *

How do you want to receive our response to your request (or any other request-related communications)? *

Electronic (sent to the consumer’s email address)

Print (mailed to your current residential address). Please note that if you choose this option, we will still require you to verify your request by email.

Nature of consumer’s interaction with LEO Pharma (for example, is the consumer a healthcare professional, patient, caregiver, co-pay card recipient) *

Request type *

Delete my personal information.

Inform me about what categories of personal information you have collected about me, the categories of sources from which the personal information is collected, the business or commercial purpose for collecting personal information, and the categories of third parties with whom LEO Pharma shares personal information.

Provide me with access to the specific pieces of personal information you have about me.

This information will be used to process your request and for no other purpose. LEO Pharma will maintain a record of your request pursuant to applicable law.

We may require additional information to verify your identity prior to fulfilling your request. If you are an authorized agent submitting a request on behalf of another consumer, you must attach proof that you have been authorized by the consumer to operate on his/her behalf when you reply to the verification email (i.e., a valid power of attorney executed by the patient).

By clicking submit:

I attest under penalty of perjury that I am the consumer whose personal information is the subject of the request or am the authorized agent submitting this request on behalf of that consumer.
I understand that after submitting this request, I will receive a verification email to confirm my request and must respond to the email with “I approve” in order for my request to be processed.

Certification *I certify that I am 18 years of age or older and the above information is true and correct.

Data protection *I understand that LEO Pharma will keep and store personal identifiable information as described here.

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Consumer Request