OMNIPOD 5 AUTOMATED INSULIN DELIVERY SYSTEM

OmnipodPromise Order Form TM

All purchases made pursuant to this Order Form will be governed by the NHS Terms and Conditions for the Supply of Goods,
unless the Hospital/NHS Organisation placing this order is part of a Framework Agreement, in which case the terms and
conditions of the relevant NHS Framework Agreement for the Supply of Goods shall apply.
Please send completed form to [email protected] or fax to 0800 029 3835.
The Insulet Customer Care Team is available 24 hours a day, 7 days a week on 0800 011 6132 . †

Insulet International Ltd, 1 King Street, 5th Floor, London W6 9HR [email protected] > www.omnipod.com
* = Mandatory field

I would like to order the following devices and consumables:

PP-001082-UK-ENG. Omnipod 5 Starter Kit mmol/l and 1 Box (of 10) Omnipod 5 Pods
® ®
*Quantity: 1
PT-000438. Omnipod 5 1 Box (of 10) Pods ®
*Quantity:
New to Omnipod ®
Existing Omnipod user ®

*Please confirm that the customer is on, or will be on Dexcom G6 App prior to the Omnipod 5 start date? ®
Yes No
The customer must be using the Dexcom G6 App prior to receiving Omnipod 5 training. ®

*Date of Order (DD/MM/YYYY): / / *Proposed Pod Start Date (DD/MM/YYYY): / /

*Purchase Order No.:

If Insulet support is needed, please select the type of training required:

By checking this box I confirm this user requires a Live Virtual Pod Start training on the Omnipod 5 System. ®

The Pod Start Date will be subject to availability.

By checking this box I confirm this user requires In-Person Pod Start training on the Omnipod 5 System. ®

The Pod Start Date will be subject to Clinical Services Manager (CSM) availability

Patient Identifier:
Hospital Name:
Hospital Postcode: Order Contact:

Pricing as per Insulet Pricing Agreement or Framework Agreement.

Invoices to be sent to:

*Payer Name:

Delivery address of initial order:

*Contact Name:
*Address:

*Telephone: *Email:

*Further supplies will be ordered via the following method:

OPTION 1: By the Hospital attached to this account
The Hospital will order all supplies and distribute to the patient as required.

OPTION 2: Directly by patient via a personal account

An account will be set up in the individual patient’s name and invoices will be sent to the NHS Payer as appropriate.
The patient can order regular supplies of Pods (in boxes of 10).

OPTION 3: Regular deliveries by standing order as confirmed by NHS Payer

The NHS Payer agree that the named patient receive from Insulet boxes of Pods (10 Pods per box) every months.
This agreement will continue yearly until written instructions from the NHS payer is received stopping the agreement. Discretion will be used if
a request from the patient is received asking for an earlier delivery date for example in case of holiday or other period of absence.

If Option 2 or Option 3 is selected, please provide the attached document to the patient for them to read, complete and sign.

†Calls may be monitored and recorded for quality monitoring purposes. Calls to 0800 numbers are free from local landlines, but other networks may charge for these calls.
OMNIPOD 5 AUTOMATED INSULIN DELIVERY SYSTEM
®

OmnipodPromise Order Form TM

* = Mandatory field

*Patient Name:

*Date of Birth:

*If minor, Legal Guardian Name:

*Patient Email:
(If minor, Legal Guardian Email)

*Patient Mobile No.:

(If minor, Legal Guardian Mobile No.)

*Patient Address:

Consent to the processing of your personal Data

In order to complete your order for the Omnipod 5 System and provide ongoing product and customer support if you have any
®

questions, Insulet International Limited (“Insulet”) needs to process your health data (e.g. your personal data contained in this form
and details about your diabetes). By placing your signature below, you are providing your explicit consent to this processing of your
personal data for these purposes and as further described below and in Insulet’s Privacy Policy. If you are a legal guardian, this
consent applies to the processing of both your personal data, and personal data concerning the individual you represent, including
their health data.
You can withdraw your consent at any time by contacting Insulet as described below and in the Privacy Policy. If you do not wish to
consent to the processing of your personal data, please note that we will not be able to provide you with the products.

*Signature: (If minor, Legal Guardian Signature): *Date:

Direct Marketing
Insulet would love to send you personalised emails and text messages about our products and services. If you wish to receive these
messages, you can opt in by checking this box. ✓
You can unsubscribe at any time by clicking ‘unsubscribe’ in any email you receive.

Insulet’s use of your personal data

Sharing your personal data and third country data transfers
We share personal data with our service providers that act on our behalf, and with the members of the Insulet group of companies which use your
personal data in accordance with this notice. We may also share your personal data with other third parties where explicitly required by law.
Our use and sharing of your personal data may involve the transfer, storage and processing of your personal data in a country outside the United
Kingdom. Some of these countries are regarded as not providing the same level of protection as the United Kingdom, in which case we put in place
safeguards (including standard data protection clauses, and additional clauses thereto, as approved or issued by the UK Information Commissioner’s
Office) to ensure an appropriate level of protection for your personal data.

Retention of your personal data

We retain your personal data for as long as you are a customer of Insulet, and for a period after you are no longer a customer if necessary to meet our
legal obligations, including regulatory obligations related to medical devices and pharmaceutical products, and to exercise and defend our rights.

Your privacy rights

You have certain rights regarding the personal data we hold about you. You have the right to access a copy of your personal data, in certain
circumstances the right to correct or delete the personal data we hold about you, to restrict our use of your personal data, to receive a portable copy
of your personal data in a reusable electronic format, or to object to our use of your personal data. Moreover, you can withdraw your consent to our
processing of your personal data at any time. In certain situations, we may not be in a position to fully comply with your request. In that case we will
inform you about this. If you would like to discuss or exercise any of these rights, please contact us using the contact information set out below.

Contact Us
If you have questions or concerns regarding the way in which your personal data is used, please contact our Data Protection Officer at
[email protected]. If you believe that we have not been able to assist with your complaint or concern, you may contact the Information
Commissioner’s Office or submit a complaint to them.
For more information about how we use personal data, please see our privacy notice at https://www.omnipod.com/en-gb/privacy.

Insulet International Ltd is a private limited company registered in England and Wales with the registered number of 10695788
whose registered office is at 1 King Street, London W6 9HR.
VAT registration number 27296527.
©2022-2023 Insulet Corporation. Omnipod and the Omnipod logo are trademarks or registered trademarks of Insulet
Corporation in the USA and other various jurisdictions. All rights reserved. INS-OHS-10-2022-00026 V8