Chatbot Consent Form

1. Which of these common symptoms of ITP have you experienced? (check all that apply)

Low or very low platelet count

Unexplained or easy bruising

Bleeding like nosebleeds, bleeding gums, or heavy menstruation in women

Small red or purple spots on your skin (called petechiae)

None of the above

2. Which of these aspects of ITP has affected your daily life? (check all that apply)

Fatigue

Brain fog, or difficulty remembering things, paying attention, and/or confusion

Anxiety about your ITP getting worse, or unstable platelet counts

None of the above

3. Which areas of your life have been affected by ITP (check all that apply)?

4. Are you satisfied with your treatment(s) for ITP?

Yes

Not currently on treatment

I am a:

Patient

Caregiver

First Name *

Last Name *

Email Address *

Phone Number *

ZIP/Postal Code *

*By checking this box, I consent that Sanofi and its third-party business partners (such as marketing agencies and market research firms) may collect, use and share with one another the information I provide in order to contact me by mail, email, fax, telephone and/or text message, and send me information about rare blood disorders and relevant Sanofi products, promotions, services, and research studies, ask my opinion about such information and topics, including through market research and disease-related surveys, and to de-identify it for use in performing research, education, business analytics, marketing studies, and other commercial purposes. I understand that text messaging rates may apply. Your information will not be sold to any third party but may be provided to regulatory authorities if required. I may opt out of continued receipt of such communications at any time by emailing RBDPatientSolutions@sanofi.com.

*I certify that I am at least 18 years old.

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.

This is required

Sign up to get your results

Thanks for signing up!