Fulvestrant Enrollment

1. Medication information and requested services

Prescription information: Fulvestrant Pre-filled Syringe 50mg/mL

New Prescription

Renewal

Healthcare provider enrolling the patient

Physician

Nurse

Drug Access Navigator

Pharmacist

Requester name

Requester email

Requester phone

Requester fax

Cancer center

Address

Treatment start-date

DD slash MM slash YYYY

Medication doses

Cycles

2. Patient Details

Name

First Last

Patient address

Address Province Postal Code

Date Of Birth

DD slash MM slash YYYY

Primary Phone

Other Phone

Patient's Insurance

No insurance

Public

Private

Insurer application date, if applicable

DD slash MM slash YYYY

Best time of day to contact

Morning

Afternoon

Evening

No preference

If unavailable, can the Program leave a message?

Yes

Preferred language

English

French

Other

3. Prescriber details

Prescriber name

Office name

Prescriber address

Office phone

Office Fax

Office contact name

Office email

Preferred method of communication

Phone

Fax

4. Pharmacy details

Pharmacy

Pharmacy name

Pharmacy address

Pharmacy phone

Pharmacy fax

Pharmacy email

5. Patient consent

Consent

I have read and agree to the patient consent below or on the reverse side of this form. By signing the consent, I consent to enroll in the Program and agree to the collection, storage, use, and disclosure of my Personal Information as described herein.

Consent

I also consent to receiving electronic communications via the email address I have provided, specifically for the delivery of services offered by the program. I understand that I may withdraw my consent to electronic communications at any time.

Patient’s signature

Patient consent section

What is the SteriMax Patient Support Program?

The SteriMax Patient Support Program is a patient support program (“Program”) provided by SteriMax Inc. and/or its affiliates (collectively “SteriMax”, “we”, “us”, “our”) to provide some patient support services to Canadian patients who have been prescribed or dispensed certain SteriMax product(s). Your healthcare professional believes you could benefit from the Program. The Program services may include health/product in formation, insurance and reimbursement assistance, and/or treatment services (the “Services”).

External (third -party) service providers are assisting SteriMax with the provision of the Services and administration of the Program: a third -party service provider handles the Program registration process and call centre, and another has been appointed as administrator of the Program (i.e. rendering the Program’s Services). In both cases, their employees and/or agents handle your Personal Information in accordance with privacy laws and SteriMax privacy/data protection standards. You agree that SteriMax res erves the right to appoint other third -party service providers to administer the Program, and you will be notified should the administrator of the Program change, including in the case of administration by a SteriMax department; your Personal Information w ill continue to be protected with equivalent safeguards.

Your participation in the Program is voluntary. If you choose not to participate, neither your medical treatment nor your insurance coverage eligibility will be impacted. However, if you do not participate, you cannot receive assistance or Services from the Program. The Program is not intended to provide medical advice or medical diagnoses. You agree to seek the advice of your physician or other qualified healthcare professional if you have health concerns, and not to disregard professional medical advice based on information obtained from the Program. SteriMax reserves the right to modify or terminate the Program at any time without prior notice.

Why is Personal Information collected, and for which purposes and with whom could it be shared?

Your personal information, including your personal health information, such as your date of birth, contact information, drug/medication information, and insurance/financial information (collectively “ Personal Information ”) is collected to communicate with you and to provide you with Program Services, audit or monitor the Program, and perform certain activities as required or permitted by law, including to process and report adverse events (“ AEs ”). We, and our third -party service providers, may contact you using the contact information you have provided (e.g. email, phone, or other). If we reach you on your cellphone, we will not assume any resulting carrier charges. Only relevant personnel will have access to your Personal Information.

Your Personal Information may be collected from and disclosed to healthcare professionals, insurance providers, government agencies or other third parties, as needed for the Program’s administration and Services. Our third -party providers are contractually obliged to follow strict data protection and security requirements.

In the case of AE processing and reporting to regulatory authorities, if monitoring or auditing is performed, or if required and/or permitted by law, it may be that SteriMax employees or agents will have access to your Personal Information. Your Personal Information will be maintained for the duration of your enrollment in the Program and as may be required thereafter to meet legal requirements.

The administrator or SteriMax agents may de-identify, aggregate (combine with other data), and/or anonymize your Personal Information to conduct analyses for commercial or research/publication purposes, or to improve the Program. Such de-identified aggregate or anonymized data may be shared with SteriMax for these same purposes. Your Personal Information may be stored or processed outside of your province/territory or Canada, including for AE processing and reporting requirements. In such cases, SteriMax ensures that your Personal Information is protected; however, your Personal Information may be subject to the laws of foreign jurisdictions, with a different level of protection than your country of residence. To request access or correction to your Personal Information or to make inquiries or complaints you may contact: fulvestrant@bayshore.ca .

What happens if I withdraw from the Program?

You may revoke your consent at any time by sending a signed letter of revocation to fulvestrant@bayshore.ca . Withdrawing your consent will result in the termination of your participation in the Program and its Services; no new Personal Information will be collected. The file containing your Personal Information will be maintained during the term of the Program for monitoring and regulatory purposes; de-identified, aggregated, or anonymized data may continue to be used as described above.

Communicating with the Program

The Program may wish to contact you via telephone or electronic means; you will have the opportunity to opt out from such communications. By signing this consent form, you agree to an initial contact by representatives of the Program, acting on behalf of S teriMax, via either telephone or electronic means (such as by email or text message), using the contact information you have provided.

For more information, please refer to the Product Monograph of the applicable SteriMax product.

6. Healthcare provider signature

Consent

Verbal consent has been obtained from the patient to enroll the patient in the Program and for the collection, storage, use, and disclosure of their Personal Information as described herein.

Healthcare provider's signature: