Patient Educator Tool

*All fields are required.

First Name

Last Name

Email Address (name@domain.com)

Phone Number

Format: (000) 000-0000.

ZIP Code

Street Address

Street Address Line 2

ZIP Code

In order for Acadia Pharmaceuticals Inc. and its representatives and agents (collectively, “Acadia”) to contact you with information about our programs, such as by connecting you to a Patient Educator, Acadia needs your consent to collect and process your information and to contact you.

Consent for Collection & Disclosure of Health Info 
I agree that Acadia Pharmaceuticals Inc. and its representatives and agents (collectively, “Acadia”) may use and disclose personal data about me and (if I am a caregiver) my patient to contact me about the Patient Educator program, and that I have the permission of my patient (as applicable) to agree on their behalf. To provide me with this service, Acadia may process health information about me or my patient (as applicable), such as: individual health conditions, diagnosis, symptoms, medication, and inferences derived from the same (collectively, “Health Information”), and disclose this Health Information to its service providers, affiliates, and as otherwise described in Acadia’s Privacy Policy, available at: https://acadia.com/privacy/.

I understand that I am not required to consent, but that if I do not consent, I will not be contacted or connected with the programs I select. If I consent, I have the right to withdraw consent and exit the program on behalf of myself and my patient (as applicable) at any time by contacting patienteducator@acadia-pharm.com or by submitting a request through Acadia’s Privacy Policy.

Opt-in for Text Messages (Optional)
I agree that Acadia may contact me via text message at the above phone number regarding the Program and other Acadia products and services. I confirm that I am the subscriber for the mobile telephone number(s) I provided on this form, and I agree to notify Acadia promptly by contacting patienteducator@acadia-pharm.com or Acadia Pharmaceuticals Inc. Attn: Patient Educator Lead, 12830 El Camino Real, Suite 400, San Diego, CA 92130 if any of my numbers change in the future. I understand that my wireless service provider’s message and data rates may apply. I can opt out of future communications by responding STOP to any text. I understand that these communications may use prerecorded/artificial voice messages and/or an automated system that I do not need to agree to receive calls or texts as a condition of purchasing or receiving any goods or services from Acadia.

I have the right to withdraw my consent at any time by submitting a request through Acadia’s Privacy Policy: https://acadia.com/privacy/. I may unsubscribe at any time using the unsubscribe link in any email.

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