Patient Certification

I hereby voluntarily agree, consent and authorize EmSahay (Sahayak) - Patient Assistance Program Team, service provider of Emcure Pharma Ltd, to have access to my information for the sole purpose of administration of the program for which I have made this application.

I hereby agree, consent and authorize Emcure Pharma, EmSahay (Sahayak) - Patient Assistance Program Team, any third party appointed by

Emcure Pharma Private Limited to record information for documentation processes. I hereby agree, consent and authorize EmSahay (Sahayak)- Patient Assistance Program Team to contact me for program-related information.

I agree that if this enrollment application is approved, only then my participation in the program will be confirmed and voluntary.

I hereby agree and understand that the Patient and treating physician certification is mandatory for enrollment into the program.

I hereby agree and understand that the drug assistance under this Patient Assistance Program will be dispatched only to my HCP/Doctor's address for supply of medicine as specified by me in this form.

I understand that while Emcure Pharma takes all reasonable efforts to supply/provide product(s) under this Program as per the prescription of the HCP, Emcure Pharma assumes no responsibility whatsoever including that of any claims, damages and / or compensations on account of any delayed shipments beyond its control. I hereby release Emcure Pharma from all and every claims, liabilities, and damages etc. arising out of any such delays in delivery of the product.

I confirm that I am citizen of India.