{"id":5340,"date":"2026-03-03T21:51:20","date_gmt":"2026-03-04T02:51:20","guid":{"rendered":"https:\/\/test-arcutis-canada.pantheonsite.io\/?page_id=5340"},"modified":"2026-03-03T22:36:25","modified_gmt":"2026-03-04T03:36:25","slug":"5340-2","status":"publish","type":"page","link":"https:\/\/www.arcutis.ca\/fr\/5340-2\/","title":{"rendered":""},"content":{"rendered":"\n<p class=\"form-text wp-block-paragraph\">Welcome! This Privacy Request Form allows consumers in states with U.S. Privacy Laws to submit privacy rights requests to Arcutis Biotherapeutics, Inc. The privacy rights available to you may vary depending on your state of residence. To submit a request to exercise your privacy rights, please select and enter the appropriate fields on this form. If applicable, Arcutis will take steps to verify your identity and affiliation with us and may request additional information from you to verify your identity or as necessary to process your request.<\/p>\n\n\n\n<p class=\"form-text wp-block-paragraph\">Arcutis will use reasonable efforts to provide you with appropriate information related to your request. In the event we cannot honor your request, we will explain why we cannot do so.<\/p>\n\n\n\n<p class=\"form-text wp-block-paragraph\">If you are a clinical trial subject, please contact the Principal Investigator on the relevant study.<\/p>\n\n\n\n<p class=\"form-text wp-block-paragraph\">We will contact you if we need any additional information.<\/p>\n\n\n\n<p class=\"form-text wp-block-paragraph\"><strong>California Notice of Right to Opt Out of Sales\/Share and Limit Use of Sensitive Personal Information<\/strong>: Residents of California have the right to opt-out of the sale\/sharing of their personal information and the right to limit the use of their Sensitive Personal Information to the purposes authorized by the CCPA. To exercise these rights, please fill out the form below or call us toll free at <a href=\"tel:844-427-2884\">844-4ARCUTIS<\/a>.<\/p>\n\n\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Privacy Request Form<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\u00ab\u00a0<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/fr\/wp-json\/wp\/v2\/pages\/5340' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='row gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_38\" class=\"form-group col gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><p style=\"    padding-bottom: 0;\n    margin-bottom: 0;\n    padding-top: 40px;\" class=\"gform_required_legend\">\u201c<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u201d indicates required fields<\/p><\/div><div id=\"field_5_16\" class=\"form-group col gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_5_16'>Select Request Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container  ginput_container_select'><select name='input_16' id='input_5_16' class='form-control large form-control-lg gfield_select custom-select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='form-control gf_placeholder'>Select Request Type*<\/option><option value='Know Information About the Processing of My Personal Information' >Know Information About the Processing of My Personal Information<\/option><option value='Correct My Personal Information' >Correct My Personal Information<\/option><option value='Delete My Personal Information' >Delete My Personal Information<\/option><option value='Access Specific Pieces of Personal Information and Data Portability' >Access Specific Pieces of Personal Information and Data Portability<\/option><option value='Do Not Sell\/Share My Personal Information' >Do Not Sell\/Share My Personal Information<\/option><option value='Limit the Use of My Sensitive Personal Information' >Limit the Use of My Sensitive Personal Information<\/option><option value='Revoke Consent' >Revoke Consent<\/option><option value='Appeal Decision' >Appeal Decision<\/option><\/select><\/div><\/div><div id=\"field_5_26\" class=\"form-group col gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><legend class='gfield_label gform-field-label' >Scope of your request (choose one)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_26'>\n\t\t\t<div class='gchoice custom-control custom-radio gchoice_5_26_0'>\n\t\t\t\t\t<input class='custom-control-input' class='gfield-choice-input' name='input_26' type='radio' value='My request relates to all Personal Information collected about me'  id='choice_5_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class='custom-control-label' for='choice_5_26_0' id='label_5_26_0' class='gform-field-label gform-field-label--type-inline'>My request relates to all Personal Information collected about me<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice custom-control custom-radio gchoice_5_26_1'>\n\t\t\t\t\t<input class='custom-control-input' class='gfield-choice-input' name='input_26' type='radio' value='My request relates to Personal Information collected about me between specific dates'  id='choice_5_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class='custom-control-label' for='choice_5_26_1' id='label_5_26_1' class='gform-field-label gform-field-label--type-inline'>My request relates to Personal Information collected about me between specific dates<\/label>\n\t\t\t<\/div><\/div><\/div><\/div><div id=\"field_5_37\" class=\"form-group col gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><p>Please select the date range for your request: <\/p><\/div><div id=\"field_5_20\" class=\"form-group col gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_5_20'>Start Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container  ginput_container_date'>\n                            <input name='input_20' id='input_5_20' type='text' value='' class='form-control datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_5_20_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_20_date_format' class='form-control screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_20' class='form-control gform_hidden' value='https:\/\/www.arcutis.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_21\" class=\"form-group col gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_5_21'>End Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container  ginput_container_date'>\n                            <input name='input_21' id='input_5_21' type='text' value='' class='form-control datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_5_21_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_21_date_format' class='form-control screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_21' class='form-control gform_hidden' value='https:\/\/www.arcutis.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_28\" class=\"form-group col gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><legend class='gfield_label gform-field-label' >On whose behalf are you submitting this request?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_28'>\n\t\t\t<div class='gchoice custom-control custom-radio gchoice_5_28_0'>\n\t\t\t\t\t<input class='custom-control-input' class='gfield-choice-input' name='input_28' type='radio' value='Myself'  id='choice_5_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class='custom-control-label' for='choice_5_28_0' id='label_5_28_0' class='gform-field-label gform-field-label--type-inline'>Myself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice custom-control custom-radio gchoice_5_28_1'>\n\t\t\t\t\t<input class='custom-control-input' class='gfield-choice-input' name='input_28' type='radio' value='As an authorized agent on behalf of someone else'  id='choice_5_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class='custom-control-label' for='choice_5_28_1' id='label_5_28_1' class='gform-field-label gform-field-label--type-inline'>As an authorized agent on behalf of someone else<\/label>\n\t\t\t<\/div><\/div><\/div><\/div><div id=\"field_5_29\" class=\"form-group col gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_5_29'>Authorized agent\u2019s first name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container  ginput_container_text'><input name='input_29' id='input_5_29' type='text' value='' class='form-control large form-control-lg'    placeholder='Authorized agent\u2019s last name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_30\" class=\"form-group col gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_5_30'>Authorized agent\u2019s last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container  ginput_container_text'><input name='input_30' id='input_5_30' type='text' value='' class='form-control large form-control-lg'    placeholder='Authorized agent\u2019s last name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_31\" class=\"form-group col gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_5_31'>Authorized agent\u2019s email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container  ginput_container_text'><input name='input_31' id='input_5_31' type='text' value='' class='form-control large form-control-lg'    placeholder='Authorized agent\u2019s email address*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_17\" class=\"form-group col gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_5_17'>I am a(n)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container  ginput_container_select'><select name='input_17' id='input_5_17' class='form-control large form-control-lg gfield_select custom-select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='form-control gf_placeholder'>I am a(n)*<\/option><option value='Patient' >Patient<\/option><option value='California Health Care Provider' >California Health Care Provider<\/option><option value='Caregiver' >Caregiver<\/option><option value='Consumer' >Consumer<\/option><option value='Contractor' >Contractor<\/option><\/select><\/div><\/div><div id=\"field_5_34\" class=\"form-group col gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible col-12\"><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex row ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_34'>\n                            \n                            <span id='input_5_34_3_container' class='d-block col name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_34.3' id='input_5_34_3' value=''   aria-required='true'   placeholder='First Name*'  \/>\n                                                    <label for='input_5_34_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_34_6_container' class='d-block col name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input class='form-control' type='text' name='input_34.6' id='input_5_34_6' value=''   aria-required='true'   placeholder='Last Name*'  \/>\n                                                    <label for='input_5_34_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/div><div id=\"field_5_18\" class=\"form-group col gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_5_18'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container  ginput_container_email'>\n                            <input name='input_18' id='input_5_18' type='email' value='' class='form-control large form-control-lg'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_5_18\" \/>\n                        <\/div><div class='gfield_description small form-text text-muted ' id='gfield_description_5_18'>(Please use the email address you have previously provided to Arcutis)<\/div><\/div><div id=\"field_5_35\" class=\"form-group col gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible col-12\"><label class='gfield_label  gform-field-label' for='input_5_35'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container  ginput_container_phone'><input name='input_35' id='input_5_35' type='tel' value='' class='form-control large form-control-lg'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_5_35\"  \/><\/div><div class='gfield_description small form-text text-muted ' id='gfield_description_5_35'>(Please use the phone number you have previously provided to Arcutis)<\/div><\/div><div id=\"field_5_19\" class=\"form-group col gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible col-12\"><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_19.1' id='input_5_19_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_19_1' >I acknowledge that\u00a0Arcutis\u00a0will collect, use, and disclose my personal information in accordance with the <a target=\"_blank\" href=\"\/privacy\/\">Arcutis Privacy Notice<\/a>.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_19.2' value='I acknowledge that\u00a0Arcutis\u00a0will collect, use, and disclose my personal information in accordance with the &lt;a target=&quot;_blank&quot; href=&quot;\/privacy\/&quot;&gt;Arcutis Privacy Notice&lt;\/a&gt;.' class='gform_hidden' \/><input type='hidden' name='input_19.3' value='5' class='gform_hidden' \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' 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