CareConnectPSS Request Information Form

Which rare diseases are you interested in learning more about?
(Choose one):

ASMD (Acid sphingomyelinase deficiency)

Fabry disease

Gaucher disease

Mucopolysaccharidosis I (MPS I)

Pompe disease (Glycogen storage disease, type II: Acid maltase deficiency)

What kind of support are you interested in? (Choose all that apply):

Treatment Information

Patient Support Program

Rare Disease Event Information

First Name *

Last Name *

Email *

Phone *

Zip Code *

How would you like to be contacted?

Phone

Please choose an option below that best describes you:

I am living with a rare disease

I am a caregiver of a person living with a rare disease

Other

By checking this box, I certify that I am at least 18 years of age.

By checking this box, I consent that Sanofi and service providers collect and use the information I provide to contact me and send me materials about products, disease education, and financial assistance

By checking this box, I consent that Sanofi also may use my information for market research or to evaluate and improve the company’s service and program. I understand that Sanofi and companies providing services to Sanofi will not sell or rent my personally identifiable information.

You may have certain rights under applicable data privacy laws regarding the personal information that you provide, including the right to withdraw consent from future collection or sharing of your information. For further information regarding these rights, please reference Sanofi US Privacy Policies and Consumer Health Data Privacy Policy .

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