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Patient Intake Form | Rhythm InTune Patient & Caregiver Support

Please answer the following questions so we can put you in touch with a Rhythm InTune Patient Education Manager (PEM) for personalized support

Your privacy is important to us. All information will be encrypted and securely stored.

Tell us about you or your loved one’s condition.

Step 1:

Step 2:

*Required information.

What conditions have you or your loved one experienced or been diagnosed with?*

Check all that apply.

Bardet-Biedl syndrome (BBS)

Overweight/obesity

Intense, hard-to-control hunger

Inherited retinal disease

Retinitis pigmentosa

Other vision impairment

Kidney problems

None of the above

Please select an option.

Are you 18 years or older and a U.S. resident?*

Yes

No

This is required.

Are you filling out this form for yourself or a loved one?*

Myself

A loved one

This is required.

What is your first name?*

This field is required.

What is your last name?*

This field is required.

What is your email address?*

This field is required.

Please enter a valid email address.

What is the best way to reach you?*

Phone Call

Text

Email

This is required.

Is it okay for the Patient Education Manager to leave a detailed message?*

Yes

No

This is required.

Is it okay for the Patient Education Manager to send a text message?*

Yes

No

This is required.

What is your phone number?*

We use your phone number to contact you about Rhythm InTune services only. We do not sell or disclose your phone number and other personal information collected in the assessment to third parties.

This field is required.

Please enter a valid phone number.

When is the best time to reach you?*

Morning (8:00 AM to 12:00 PM)

Afternoon (12:00 PM to 5:00 PM)

Evening (5:00 PM to 9:00 PM)

This is required.

What state do you live in?*

This field is required.

I agree to receive information from Rhythm Pharmaceuticals, its products and services, by mail, email, phone, and text. I understand that I may opt-out of email messages by following the unsubscribe link in the message or as detailed in Rhythm Pharmaceuticals™ Privacy Policy. By providing my phone number, I agree to receive phone calls and/or text messages from Rhythm Pharmaceuticals. I understand that, once enrolled, the frequency of text alerts from Rhythm Pharmaceuticals will vary. I understand that consent is not required to purchase goods or services and that standard message and data rates of my carrier may apply. To stop text messages from Rhythm Pharmaceuticals, reply STOP.*

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