WAKIX Pregnancy Registry

Please answer these questions to ensure you are eligible to participate in the WAKIX Pregnancy Registry. Please note, this registry is for US patients only.

Are you currently or recently pregnant and diagnosed with narcolepsy?

Yes

Thank you for confirming your eligibility to enroll!

Please complete this form and a registry team member will contact you with more information about participating in the registry. Please note, this registry is for US patients only.

I authorize the WAKIX Pregnancy Registry to contact me and/or leave a message for me at these numbers; or to contact me via email at the address listed below. I agree to the Registry referencing the “WAKIX Pregnancy Registry” in messages or emails addressed to me.

Potential Participant Name*

Email*

Street Address*

City

State / Province*

Zip / Postal Code

Primary Phone Number*

Alternate Phone Number

The registry is open from 8:30 AM - 5:00 PM ET.

Please identify the best time of day for contact.

Please identify the best day for contact.

Monday

Tuesday

Wednesday

Thursday

Friday

My Health Care Provider’s Name is:

Privacy Statement:

Pharmaceutical Product Development, LLC (PPD) respects that privacy is important to you. The information you provide on this form will be used to contact you for the purposes of assessing your eligibility to participate in the WAKIX Pregnancy Registry. This information will be held by PPD and not shared with the study sponsor (Harmony Biosciences, LLC) or any other third party without your written permission. In the event you choose not to enroll, Registry staff will request permission to share your contact information with Harmony Biosciences, LLC in order for them to contact you for safety follow up about your pregnancy. If you do not provide permission, and do not enroll in the Registry your contact details will be deleted.

Enroll for WAKIX Pregnancy Registry

Thank you for confirming your eligibility to enroll!