To: Medigas, Division of Linde Canada Inc. (“Medigas”) I wish to purchase certain medical equipment, supplies and accessories from Medigas through Medigas’ website.

I understand that:

• In connection with my purchase of medical equipment, supplies and accessories from Medigas, Medigas will collect, use, store and disclose personal information about me, potentially including health information, (i) to be able to contact me in the event of a product recall or to provide to me other safety notifications or information regarding the medical equipment, supplies and accessories that I purchase from Medigas; (ii) to provide responses to regulatory or self-regulatory bodies having jurisdiction over Medigas in connection with inquiries or investigations by such bodies; and (iii) to advise me of services or information that may be of interest to me.
• From time to time Medigas may use the services of other companies located in Canada, in the United States or elsewhere to assist Medigas with timely and effective product recalls and communication of services or information, and for such purposes Medigas may wish or need to disclose personal information about me to such companies as is reasonably necessary for the purpose of conducting such product recalls or providing such communications, subject to appropriate undertakings of confidentiality that are consistent with the Medigas privacy statement.
• Medigas will not collect, use, store or disclose personal information about me except as is reasonably necessary for the purposes described above and otherwise as the law may require or allow.
• I understand that I may withdraw my consent for Medigas to use and disclose some or all of the personal information that it has collected from me at any time, except that I cannot withdraw my consent to use and disclosure for the purposes of product recalls; safety notifications or information; or responses to regulatory or self-regulatory bodies. If I choose to withdraw this consent, I will no longer be able to purchase products from Medigas’ web site.
• I understand that I can consult a Medigas representative and ask questions about how my personal information is collected, used, stored and disclosed by Medigas, by calling the telephone number disclosed in this website under ["Contact Us"], and I attest that, prior to giving this Consent, I have either done so or I have waived my right to do so.
• I have reviewed Medigas' privacy statement disclosed elsewhere in this website and understand and agree to that policy.

Accordingly, I hereby:

• Agree that Medigas may collect, use, store and disclose personal information about me, as is reasonably necessary for the purposes described above;
• Consent to the transmission of my personal information to third parties, whether in Canada, in the United States or elsewhere, as is reasonably necessary for the purposes described above;
• Consent to the use of e-mail to the web address provided by me to Medigas for the purposes of giving product recall, safety notifications or safety information; and
• Agree to promptly inform Medigas of any changes to my name, address or contact information.

I understand that if I wish to withdraw this consent at any time, or would like to access my personal information held by Medigas, I may do so by contacting Medigas at 1-877-333-1696 or by email to medigas.cpap@linde.com.

Please print and retain for your records.