By signing this form, I acknowledge that:

• I am a healthcare provider, or an authorized representative of the facility or practice listed on the form above.
• I understand that this enrollment form offers the facility, practice, or provider listed above, the opportunity to be included in a provider directory.
• Further, I agree to be contacted by a Recordati Rare Diseases representative by mail, fax, e-mail or telephone for the purposes of reviewing and validating the submitted registration information.
• There will be no exchange of fees or remuneration of any kind in exchange for registration or participation in the directory.
• There is no guarantee to obtain patients through being listed in this directory. This directory is not a referral service.
• Recordati Rare Diseases reserves the right to not list information in the directory.
• Inclusion of a healthcare professional in this directory does not represent an endorsement by or a recommendation from Recordati Rare Diseases.
• I can update my profile or opt-out of the directory at any time by contacting Recordati Rare Diseases at: locator@cystinosisinfocus.com.

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