The ProVital^® Support Program
by AMGEN Entrust^® Patient Support Services^*

By providing my email address, I agree to receive, electronically, communications from McKesson Canada Corporation (“McKesson”) acting on behalf of Amgen Canada, Inc. containing information and updates relating to my enrolment in the ProVital^® Support Program. I understand that I may withdraw my consent to such communications at any time by providing notice to McKesson at: 70 Wynford Dr., P.O. Box 383, North York, ON, M3C 2S7 or via email at provital@patientdirect.ca

By signing this form, I acknowledge that I have read and understand the information below and consent to the collection, use and disclosure of my personal information, including personal health information, by McKesson, Amgen and their authorized agents and service providers as explained. I further consent to being contacted from time to time by McKesson, Amgen or their authorized agents for the above-noted purposes.

The ProVital Support Program (“Program”) is sponsored by Amgen Canada Inc. (“Amgen”) and administered by McKesson, a third-party provider, on behalf of Amgen. Other service providers may be appointed by Amgen to administer the Program from time to time. The personal information that you and/or your healthcare providers (including your doctor and pharmacy), insurers or payers provide to the Program, including your name, contact information and prescription information, will be used to manage and administer the Program, including provision of Program services to you, such as reimbursement assistance and administering, training or assisting in therapy (e.g., self-injection training), and provision of information about the Program to you.

Amgen has a legal obligation to report adverse drug events to various local and international health authorities and to monitor product complaints. Personal information provided to the Program may be (i) monitored by Amgen or its service providers for safety-related data and product complaints in order to ensure compliance with these legal reporting requirements, and (ii) reported to local or international health authorities. Amgen may contact you or your physician for additional information to fulfil its reporting obligations. Your personal information may be combined with the information of others who participate in the Program in order to generate aggregated data that do not contain identifying information (“Aggregated Data”). Aggregated Data may be used by Amgen and its service providers to improve and/or refine the Program, to design and implement other patient programs and for research purposes including the identification of trends such as product utilization, adherence or outcomes.

For these sole purposes, McKesson may, on a confidential basis, collect your personal information and share it with your healthcare providers, insurers and/or other payers, Amgen and/or Amgen’s agents and service providers (e.g., information technology providers). If, from time to time, another service provider is appointed by Amgen to administer the Program, your personal information will be transferred to this service provider to ensure the continuity of the Program services to you. Please note that Amgen and its service providers may store or process your personal information outside of Canada (including in the United States), where local laws may require the disclosure of personal information to governmental authorities under circumstances that are different than those that apply in Canada. In addition, your personal information may be used or disclosed to third parties when permitted or required by applicable laws, court orders or government regulations (collectively, “Applicable Laws”).

Your personal information will be retained only for as long as is needed to fulfil the purposes for which it was collected and in order to comply with Applicable Laws. Industry standard safeguards will be used to protect the security of the personal information that is collected. You may contact the Program’s Privacy Officer at any time to update or access your personal information, modify or withdraw your consent (in part or in full), express a privacy-related concern, or inquire about the privacy practices of the Program (including those related to foreign information processing). The Privacy Officer can be reached at privacycanada@amgen.com or Amgen Canada Inc., Attn: Chief Privacy Officer, 6775 Financial Drive, Suite 300, Mississauga, ON, L5N 0A4. Please note that if you modify or withdraw your consent, your ability to receive the Program services may be limited.