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HO Form | Rhythm InTune

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

Your privacy is important to us. All information will be encrypted and securely stored, View privacy policy here.

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

Step 1:

Step 2:

*Required information.

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

Check all that apply.

Acquired hypothalamic obesity (HO)

History of brain tumor or brain injury

Overweight/obesity

Increased hunger or constant, hard-to-control hunger

Decreased physical activity

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?*

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What is your last name?*

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What is your email address?*

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Please enter a valid email address.

What is the best way to reach you?*

Phone Call

Text

Email

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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)

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What state do you live in?*

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Is there anything specific you’d like to discuss with a Rhythm InTune Patient Education Manager (PEM)?

I agree to receive communications from Rhythm Pharmaceuticals by mail, email, phone, and text messaging about Rhythm Pharmaceuticals, its products, and services, and for market research and internal related purposes. I understand that 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 messages from Rhythm Pharmaceuticals may vary and that standard messaging and data rates of my carrier may apply. I may stop and opt-out of email and/or text messages by following the unsubscribe link or directions within such messages and that I may stop and opt out of other communications by contacting Rhythm Pharmaceuticals at privacy@rhythmtx.com. I understand that my consent is not required to purchase goods or services from Rhythm Pharmaceuticals.*

For further information on how my information may be collected, managed and used by Rhythm, please see our Privacy Policy

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US-RHY-2500014 (01.03/2025)

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