Patient Information (To be filled by the patient)
Date of Birth: Gender (Male/Female):
Address for correspondence:
Mobile No: Email id: NA
HOPE is a Patient Assistance Program by Dr. Reddy’s Laboratories Limited, managed by [HDU HEALTHCARE PVT LTD] (hereinafter the “Agency”), for reducing the financial burden of epilepsy treatment on patients wherein if patients will be eligible to receive 4 strips of Briviact on purchase of 18 strips of Briv subject to the terms mentioned below (hereinafter ‘Programme” ) The Agency is a service provider who is assisting Dr. Reddy’s to conduct this Programme by providing all the support required for conducting this Program. The duration of this Programme is 1 (one) year starting from the month of [01-02-2023] to [01-02-2024 subject to availability of stock[KSG1] for Briviact..
I hereby agree and acknowledge that I have been referred for this Program by my treating doctor, Dr. Tushar Muni. I understand and acknowledge that in order to participate and register for this Program and to avail the benefit of 4 strips of Briviact, I have to submit the invoice for purchase of 18 strips of Briv to the Agency. I agree and understand that only upon successful submission of the aforesaid invoices along with the doctor’s prescription will I be registered under the above mentioned Programme by the Agency. I have been explained the details of the Programme by the Agency and I agree to participate in this Programme out of my own volition being fully aware that Briviact and Briv are generic brand names for the same composition and formulation that has been prescribed by my doctor.
I agree that I have read and fully understood the terms of this Programme and I agree to abide by the foregoing as a condition of my participation under this Programme.
Signature of the Patient: ___________________________
Name of Patient: _____________________________