Privacy Act Opt Out Form

Note: Fields marked with an asterisk () are required.

First Name

Middle Initial

Last Name

Phone

I confirm I'm the person above

I confirm I'm an authorized agent

Agent First Name

Agent Middle Initial

Agent Last Name

Phone

Agent Email

Authorization Document
I certify that I am an authorized agent given explicit permission on behalf of the Healthcare Professional to request an opt out on their behalf. I certify the uploaded document to the best of my knowledge is authentic and provided directly from the HCP.

I certify that I am the person above, or an authorized agent given explicit permission on behalf of the Healthcare Professional, requesting to be opted out of further communications from Conisus. I agree and understand that this opt out is for Conisus only. This opt out may not render effect upon agreements executed by the person above and a client of Conisus. I understand that I need to contact the client to opt out of their future communications or to remove personal information from their databases. I understand by clicking "submit" my request will be submitted and my request will be screened to determine if further follow up is needed. This request may take up to 10 business days to become effective. I further hereby acknowledge that should follow up be required to determine identity or authority, this request may be delayed.

Privacy Act Opt Out Form

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