Symbolic Care patient informed consent form

I understand that I am enrolling in the Symbolic Care Patient Support Program, a structured initiative designed to support patients prescribed Semaglutide for weight management by their treating physician.

The program aims to provide:

• Guidance on proper Semaglutide pen usage and administration techniques
• Dietary counseling and nutritional guidance tailored to weight management goals
• Lifestyle modification recommendations and behavioral support
• Regular follow-up through structured patient touchpoints
• Educational resources to optimize treatment outcomes

2.1 Telephone / Call / Message-Based Support

I hereby give my explicit consent to receive telephone calls / SMS / WhatsApp Messages from Symbolic Care support team members for the following purposes:

• Understanding and proper usage of the Semaglutide pen (injection technique, storage, handling)
• Dietary guidance and nutritional counseling for weight management
• Lifestyle modification recommendations (physical activity, sleep, stress management)
• Monitoring of overall program experience and addressing any concerns
• Appointment reminders and follow-up scheduling

I understand that:

• Support calls will be made to the phone number I have provided above
• Calls will typically be made during business hours or at times mutually agreed upon
• I may request to reschedule calls at my convenience
• All communications will be conducted in a professional and confidential manner

2.2 Right to Refuse or Withdraw Communication Consent

I understand that I have the right to refuse, defer, or withdraw my consent for receiving support calls at any time without affecting my eligibility to continue in the program or my relationship with my treating physician. I can communicate my preference by:

• Calling: 1800 209 1979
• Emailing: symobilccare@saarathihealthcare.com
• Informing the support team during any call

3.1 Types of Personal Data Collected

As part of the Symbolic Care program, I consent to the collection and storage of the following categories of personal data:

Medical Information:

• Diagnosis (weight management with Semaglutide prescription)
• Prescribed medication details (drug name, dosage, prescribing physician name)
• Patient-reported health conditions relevant to weight management
• Semaglutide pen usage and adherence information
• Dietary habits and lifestyle patterns
• Program participation and support call interaction records

Contact Information:

• Name, contact number, email address, residential address
• Preferred mode of communication

Program Engagement Data:

• Dates and outcomes of support calls
• Topics discussed during interactions
• Patient feedback and satisfaction responses
• Program milestone achievements

3.2 Purpose of Data Collection and Storage

I understand that my personal data will be collected, processed, and stored for the following purposes:

• To provide personalized support and guidance during my enrollment in Symbolic Care
• To monitor program effectiveness and patient outcomes
• To ensure continuity of care and appropriate follow-up
• To maintain accurate program records and audit compliance
• To improve program design and support services
• For regulatory reporting and quality assurance (if required by healthcare authorities)

3.3 Data Retention

I understand that my personal data will be retained:

• During my active enrollment: For the full duration of my participation in the Symbolic Care program
• Post-enrollment: For a minimum of [specify period, e.g., 2 years] for program evaluation and regulatory compliance purposes
• After this retention period, my data will be securely archived or deleted as per regulatory requirements

I can request deletion of my data at any time by submitting a written request, subject to legal and regulatory obligations.

I confirm that my participation in the Symbolic Care program is entirely voluntary. I understand that:

• I can withdraw from the program at any time by providing written notice
• Withdrawal from the program will not affect my treatment with my physician or any healthcare services I receive
• My withdrawal will not result in any penalty or loss of benefits
• Upon withdrawal, I can request that my data not be used for future communications, while maintaining compliance with legal retention requirements

4.2 Grievance Redressal

If I have concerns about the Symbolic Care program, data handling, or support provided, I can contact:

Program Grievance Team

• Toll-Free Number: 18002091979
• Email: grievances@saarathihealthcare.com
• Postal Address: Saarathi Healthcare Pvt Ltd, 431-432, Lodha Supremus, Wagale Estate, Thane West., Tahne-400064

Data Protection Officer (if applicable)

• Contact: dpo@saarathihealthcare.com

Grievances will be reviewed and addressed within 30 days of submission.

5.1 Patient Declaration

I declare that:

• I have read and fully understood this Informed Consent Form in a language of my choice
• I have had adequate opportunity to ask questions about the program and my data will be handled
• All my questions have been answered to my satisfaction
• I am providing this consent of my own free will without any pressure or coercion
• I am at least 18 years of age (or my legal guardian has provided consent on my behalf)
• I have not withheld any relevant health information that might affect my participation
• I understand that my participation is voluntary and I can withdraw at any time

5.2 Authorization

I freely and voluntarily consent to:

• Receive support communications (telephone calls, SMS, email) as part of the Symbolic Care program
• The collection, storage, and processing of my personal data as described in this form
• The retention of my data for program support, evaluation, and regulatory compliance
• The handling of my data in accordance with applicable Indian data protection laws, including the Digital Personal Data Protection Act, 2023 (DPDPA)

This Symbolic Care Patient Informed Consent Form has been designed in compliance with:

• Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002
• Digital Personal Data Protection Act, 2023 (DPDPA)
• Guidelines for Good Manufacturing Practice (GMP) and Quality Management Systems
• Best practices for Patient Support Programs in the pharmaceutical industry
• Guidelines for healthcare communication and patient engagement