Sample Request Form | Vitafriends PKU UK

Event Sample Request Form

Please select your samples below:

* I confirm that I have PKU, or am acting as the parent/carer of someone who has PKU.

Recipient Details

Title

PKU sphere liquid:

PKU sphere powder:

PKU explore:

PKU squeezie:

PKU cooler:

PKU air:

PKU express plus:

Additional information or comments

By ticking this box, I confirm that:

I am a UK resident; and
I confirm that I am aged 16 or over and I have PKU; or
I am the parent/guardian/carer of someone who is under the age of 16 and has PKU
I expressly agree to share my personal data or that of my child, as applicable, including special category data, i.e. data concerning my health/my child’s health contained and submitted in this sample request form, with Vitaflo (International) Limited (Vitaflo), its representatives and other third parties (e.g. Vitaflo’s courier) as reasonably required in order to use and process my personal data or that of my child, as applicable, including special category data, for the following purposes (the Purpose):
- contacting my/my child’s dietitian (or other healthcare professional as detailed in this form) to obtain their approval to my use/to my child’s use of the Vitaflo product samples I have requested;
- shipping the samples to the postal address I have provided; and
- contacting and communicating with me in connection with my sample request and shipment of the samples.
I understand and expressly agree that Vitaflo, its representatives and third parties will use my personal data or that of my child, including special category data only for the Purpose and will not use or process any of my personal data and/or that of my child, including special category data, for any other purpose. I understand that after my personal data or that of my child is no longer required, my personal data or that of my child will be permanently deleted.

If you are looking for more information on how Vitaflo processes your personal data, or on Vitaflo’s approach to data security, data retention and lawful processing bases, you can access our privacy policy.