REGISTER YOUR PRACTICE WITH THE RYSTIGGO INFUSION FINDER

This information will be used to contact you about your listing and will not be listed in the RYSTIGGO Infusion Finder website. *Indicates required field.

This information will appear when a user searches for a practice near them using the RYSTIGGO Infusion Finder website. *Indicates required field.

Your registration will be complete after you read and acknowledge the Release below and click Submit.

The Practice understands that UCB, Inc., its affiliates, and/or designees would like to use contact information for the Practice on UCB’s website, at www.rystiggo.com/infusion-finder. Specifically, UCB will publish the following information for the Practice: (i) Practice name; (ii) Practice address; (iii) Practice telephone number; and (iv) Practice website (together, the “Practice Information”). The Practice understands that UCB would like to share the Practice Information as part of an online database of providers that offers RYSTIGGO^® to patients with a prescription from a physician, to allow these patients to search for nearby RYSTIGGO providers and contact information ("infusion finder").

By opting-in to this Release, I am authorizing UCB and/or its affiliates to publish the Practice Information on www.rystiggo.com/infusion-finder. The Practice hereby grants permission to UCB to publish the Practice Information on the RYSTIGGO Website and/or infusion finder for the purposes outlined in this Release.

Please note that to be included in the RYSTIGGO Website and/or the infusion finder, the Practice must have a valid state license to stock and administer RYSTIGGO. UCB will verify your submission and inform you when the infusion finder is ready to launch.

The Practice understands and agrees that:

1. The Practice has the right to refuse to sign this Release and, in doing so, UCB will not publish the Practice Information on UCB’s Website and/or the infusion finder;
2. The Practice has the right to receive and/or request a copy of this Release at any time;
3. The Practice may revoke the authorization given in this Release at any time by providing written notice of the same to UCB, and upon receipt of this revocation notice, UCB will delete the Practice Information from the RYSTIGGO Website and/or infusion finder;
4. The Practice will inform UCB of any changes to the published Practice Information and/or if the Practice ceases the administration of RYSTIGGO to prescribed patients;
5. The Practice is responsible for any errors in the published Practice Information that are caused by the Practice;
6. UCB may contact the Practice for the purpose of communicating any updates, changes, or any other news regarding the RYSTIGGO Website and/or the infusion finder;
7. UCB will exercise its discretion as to whether and when to provide listings in the RYSTIGGO Website and/or the infusion finder for particular geographic areas, and may exercise its discretion not to provide listings for certain geographic areas;
8. No fees or other remuneration have been or will be exchanged for the Practice’s inclusion in the infusion finder. UCB is not affiliated with, and inclusion in this infusion finder does not represent an endorsement of, or referral to, the Practice, nor does it represent an endorsement of any UCB product by the Practice; and
9. Nothing has created or vested in the Practice any ownership, copyright, or other rights in the RYSTIGGO Website and/or the infusion finder by virtue of this Release.

The Practice further releases UCB and its respective agents from any and all liability in connection with the publication of the Practice Information on the RYSTIGGO Website and/or the infusion finder in accordance with this Release. The Practice will neither seek nor bring any proceedings against any such parties for any claim or cause of action based upon or relating to the publication of the Practice Information pursuant to this Release.