{"id":6674,"date":"2023-10-12T23:13:10","date_gmt":"2023-10-12T23:13:10","guid":{"rendered":"https:\/\/palynziqpatient-prod-001.azurewebsites.net\/en-us\/?page_id=6674"},"modified":"2024-05-14T11:23:52","modified_gmt":"2024-05-14T11:23:52","slug":"connect-with-us","status":"publish","type":"page","link":"https:\/\/palynziq.biomarin.com\/en-us\/connect-with-us\/","title":{"rendered":"Connect with us"},"content":{"rendered":"<div id=\"acf-block-656898de1176e\" class=\"block patient-sign-up-form\">\n    <div class=\"wrapper\">\n        <div class=\"inner-wrapper\">\n            <div class=\"above-form-copy\">\n                                    <h2>Connect with us\n<\/h2>\n                                                    <p>Please complete the form below to receive the latest information about PALYNZIQ\u00ae (pegvaliase-pqpz) Injection.<\/p>\n<p>* Required fields.<\/p>\n                            <\/div>\n\n            <div class=\"block form-box\">\n                <form id=\"patient-sign-up\" name=\"Sign Up to Stay in the Know!\">\n                    <div class=\"form-item check-item form-item-valid\">\n                        <input type=\"radio\" name=\"residency\" id=\"residency-us\" value=\"us\" required=\"\" data-pristine-required-message=\"Please select an option\" data-gtm-form-interact-field-id=\"1\">\n                        <label for=\"residency-us\">I am a US resident<\/label>\n                    <div class=\"pristine-error error\" style=\"display: none;\"><\/div><\/div>\n\n                    <div class=\"form-item check-item form-item-valid\">\n                        <input type=\"radio\" name=\"residency\" id=\"residency-non-us\" value=\"non_us\" required=\"\" data-pristine-required-message=\"Please select an option\" data-gtm-form-interact-field-id=\"0\">\n                        <label for=\"residency-non-us\">I am NOT a US resident<\/label>\n                    <div class=\"pristine-error error\" style=\"display: none;\"><\/div><\/div>\n\n                    <div class=\"non-us-message\" style=\"display: none;\">\n                        <p><strong>We&rsquo;re sorry, but you must be a U.S. resident.<\/strong><\/p>\n                    <\/div>\n\n                    <div class=\"form-main-content\">\n                        <div class=\"form-columns\">\n                            <div class=\"form-item\">\n                                <label for=\"first-name\">First name<span class=\"required\">*<\/span><\/label>\n                                <input class=\"text\" id=\"first-name\" type=\"text\" required\n                                data-pristine-required-message=\"Please enter your first name\">\n                            <\/div>\n\n                            <div class=\"form-item\">\n                                <label for=\"last-name\">Last name<span class=\"required\">*<\/span><\/label>\n                                <input class=\"text\" id=\"last-name\" type=\"text\" required\n                                data-pristine-required-message=\"Please enter your last name\">\n                            <\/div>\n                        <\/div>\n\n                        <div class=\"form-columns\">\n                            <div class=\"form-item\">\n                                <label for=\"email\">Email<span class=\"required\">*<\/span><\/label>\n                                <input class=\"text\" id=\"email\" type=\"email\" required\n                                data-pristine-required-message=\"Please enter your email address\">\n                            <\/div>\n\n                            <div class=\"form-item\">\n                                <label for=\"phone-number\">Phone number<\/label>\n                                <input class=\"text\" id=\"phone-number\" type=\"text\"\n                                data-pristine-required-message=\"Please enter your phone number\"\n                                data-pristine-pattern-message=\"Please enter a valid phone number\"\n                                data-pristine-pattern=\"\/^\\(?([0-9]{3})\\)?[-. ]?([0-9]{3})[-. ]?([0-9]{4})$\/\">\n                            <\/div>\n                        <\/div>\n\n                        <div class=\"form-columns\">\n                            <div class=\"form-item\">\n                                <label for=\"zip-code\">US postal code<span class=\"required\">*<\/span><\/label>\n                                <input class=\"text\" id=\"zip-code\" type=\"text\" required\n                                data-pristine-required-message=\"Please enter your ZIP code\"\n                                data-pristine-pattern-message=\"Please enter a valid ZIP code\"\n                                data-pristine-pattern=\"\/^\\d{5}(-\\d{4})?$\/i\">\n                            <\/div>\n\n                            <div class=\"form-item\">\n                                <label for=\"dob\">Date of birth<span class=\"required\">*<\/span><\/label>\n                                <input class=\"text\" id=\"dob\" type=\"text\" placeholder=\"mm\/dd\/yyyy\" required\n                                data-pristine-required-message=\"Please enter your date of birth\">\n                            <\/div>\n                        <\/div>\n\n                        <div class=\"form-item\">\n                            <label for=\"contact-type\">Are you an individual with PKU or a caregiver to someone with PKU?<span class=\"required\">*<\/span><\/label>\n                            <select class=\"text\" id=\"contact-type\" required\n                            data-pristine-required-message=\"Please select an option\">\n                                <option value=\"\">Please select an option<\/option>\n                                <option value=\"Patient\">I have PKU<\/option>\n                                <option value=\"Caregiver\">I am someone who supports a person with PKU<\/option>\n                            <\/select>\n                        <\/div>\n\n                        <div class=\"form-item check-item\">\n                            <input type=\"checkbox\" id=\"request-connect\" name=\"request_connect\">\n                            <label for=\"request-connect\">I would like to be connected with a local BioMarin representative to learn more about PALYNZIQ.<\/label>\n                        <\/div>\n\n                        <div class=\"form-item check-item\">\n                            <input type=\"checkbox\" id=\"accept-ts-cs\" name=\"accept_ts_cs\" required\n                            data-pristine-required-message=\"Please agree to the terms of use\">\n                            <label for=\"accept-ts-cs\">By checking the box above and clicking &ldquo;Submit&rdquo; below, I confirm that I am at least 18 years old; and confirm I agree to BioMarin&#8217;s <a href=\"https:\/\/biomarin-global-privacy.com\" target=\"_blank\">Privacy Policy and CCPA Notice<\/a> and <a href=\"https:\/\/medinfoterms.com\/\" target=\"_blank\">Terms of Use<\/a>; consent to BioMarin, its successors, agents, and\/or assigns using the email address I have provided to receive more information related to PALYNZIQ and confirm I understand these communications\/materials may contain information that markets or advertises BioMarin products, goods, or services.<span class=\"required\">*<\/span><\/label>\n                        <\/div>\n\n                        <div class=\"form-item check-item\">\n                            <input type=\"checkbox\" id=\"accept-marketing\" name=\"accept-marketing\">\n                            <label for=\"accept-marketing\">By checking the box to the left and clicking \u201cSubmit\u201d below, I consent to BioMarin, its successors, agents, and\/or assigns using the phone number I have provided to phone and\/or text me with communications\/messages that contain information marketing BioMarin\u2019s products, goods, or services, including via use of an automatic telephone dialing system; and confirm I understand I am not required to provide my consent as a condition of purchasing or renting any products, goods, or services.<\/label>\n                        <\/div>\n\n                        <div class=\"form-item\">\n                            <input type=\"submit\" class=\"button\" value=\"Submit\">\n                        <\/div>\n                    <\/div>\n                <\/form>\n                <form id=\"mktoForm_3470\" style=\"display:none;\"><\/form>\n            <\/div>\n\n            <div class=\"block form-success-confirmation\" style=\"display:none;\">\n                                    <h3>Thank you!<\/h3>\n<p>We&#8217;ll be in touch soon with additional information.<\/p>\n                                            <\/div>\n        <\/div>\n    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