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IMPORTANT SAFETY INFORMATION:

Forms for Patient Testimonials

Share Your Story

QOL Medical is interested to hear from those affected by Congenital Sucrase-Isomaltase Deficiency, patients and caregivers, regarding their experience with Sucraid®. Please use the form below to share your story.

In This Section

    Name*

    Email*

    Title*

    State Where You Practice Medicine*

    For how many patients have you prescribed Sucraid®?

    What does Sucraid® mean to you and your patients?

    How does Sucraid® help in managing symptoms of Congenital Sucrase-Isomaltase Deficiency? How effective has Sucraid® therapy been for your patients diagnosed with CSID?

    If applicable, what have been your experiences and/or your patients’ experiences with QOL Medical’s patient support programs for Sucraid®, called SucraidASSIST™ (Access and Support Services in Sucraid® Therapy)?


    Consent and Release

    I hereby grant QOL Medical, the maker of Sucraid®, permission to use my first name, last name, and title (i.e., John Smith, MD), state of medical practice, and physician testimonial (which may include some or all of the information inserted above) on www.sucraid.com.

    By signing this form, I am hereby consenting to allow QOL Medical to use and disclose the information in my testimonial and acknowledge that my testimonial may be distributed to the public. I have the right to revoke this Consent and Release at any time by providing written notice of my revocation and submitting it to the Contact Person listed below. I understand that revocation of this Release will not affect any action QOL Medical took in reliance on this Release before receiving my revocation and, if applicable, a reasonable time period to remove any portions of my testimonial from websites controlled by QOL Medical. QOL Medical shall not be required to retrieve any educational, patient assistance, promotional, or other materials or disclosures that contain portions or all of my testimonial that may have been disseminated, published or otherwise disseminated prior to any such revocation.

    I hereby authorize QOL Medical and its staff to use my testimonial and any information contained herein in its patient assistance, patient education programs or promotional materials, on its websites, and in its public relations or other business efforts. I understand and approve the disclosure of all or any portion of my testimonial information on its websites or other media or to other individuals and entities that may be involved in the business, healthcare, or public relations efforts of QOL Medical.

    QOL Medical may at its/their sole discretion make any and all changes in, additions to, and deletions from the testimonial including without limitation, cuts, edits, additions, changes, rearrangement, adaptation of the information to different formats, and other changes, additions, and deletions necessary to make the testimonial usable by QOL Medical. I understand and agree that the provided information may be used on, in, or in connection with any published materials and may be used, amended, transferred, displayed, broadcast, reproduced, and/or distributed publicly or otherwise, for any purposes whatsoever, including, but not limited to, educational, promotional, or commercial purposes.

    I also release QOL Medical for any use of the provided information by third parties who intercept the materials or gain access to them over the Internet or other electronic media without QOL Medical’s permission, and for any claim of alteration, optical illusion or faulty mechanical reproduction, distortion, or illusion in reproduction. I understand that this Consent and Release does not obligate QOL Medical to use the provided information on, or in connection with, any materials.

    I waive the right of prior approval and hereby release and hold harmless QOL Medical and its staff from any and all claims for damages of any kind based on the use of my testimonial, or information in the testimonial, or by virtue of this authorization. By signing below I agree and acknowledge that I have read and understood the above Consent and Release and agree to all terms described. I am of legal age, have read this Consent and Release, and freely sign this Consent and Release of my testimonial.


    *By checking this box, I am agreeing to the terms above.

    Please enter your full name in lieu of a signature*

    *Denotes required field

    Important Safety Information for Sucraid® (sacrosidase) Oral Solution

    • Sucraid® may cause a serious allergic reaction. Patients should stop taking Sucraid® and get emergency help immediately if any of the following side effects occur: difficulty breathing, wheezing, or swelling of the face. Care should be taken when administering initial doses of Sucraid® to observe any signs of acute hypersensitivity reaction.
    • Do not use Sucraid® with patients known to be hypersensitive to yeast, yeast products, papain, or glycerin (glycerol).
    • Although Sucraid® provides replacement therapy for the deficient sucrase, it does not provide specific replacement therapy for the deficient isomaltase.
    • Adverse reactions as a result of taking Sucraid® may include worse abdominal pain, vomiting, nausea, diarrhea, constipation, difficulty sleeping, headache, nervousness, and dehydration.
    • Before prescribing Sucraid® to diabetic patients, the physician should consider that Sucraid® will enable sucrose hydrolysis and the absorption of those hydrolysis products, glucose and fructose.
    • The effects of Sucraid® have not been evaluated in patients with secondary (acquired) disaccharidase deficiency.
    • DO NOT HEAT SOLUTIONS CONTAINING SUCRAID®. Do not put Sucraid® in warm or hot fluids. Do not reconstitute or consume Sucraid® with fruit juice since the acidity of the juice may reduce the enzyme activity of Sucraid®. Half of the reconstituted Sucraid® should be taken at the beginning of the meal or snack and the other half during the meal or snack.
    • Sucraid® should be refrigerated at 36°F-46°F (2°C-8°C) and should be protected from heat and light.

    Indication

    Sucraid®(sacrosidase) Oral Solution is an enzyme replacement therapy for the treatment of genetically determined sucrase deficiency, which is part of Congenital Sucrase-Isomaltase Deficiency (CSID).