Personal Information Consent/Attestation

 

In order to participate in the Siliq Solutions Instant Savings Program and receive a benefit, you must meet certain eligibility criteria. During the enrollment process for the Siliq Solutions Instant Savings Program, you will be asked to provide personal information that may include your name, address, phone number, date of birth, Social Security number and information related to your insurance and treatment. Providing this information is necessary in order for you to participate in this program. By enrolling in this program, you permit vendors engaged by Valeant Pharmaceuticals North America LLC (“Valeant”) to use and share the personal information you provide in order for Valeant, its affiliates and its vendors to provide you with the benefits related to the activation and use of your Siliq Solutions Instant Savings card. By enrolling in this program, you agree to allow Valeant’s agents to contact you in the future about this program through the mail for as long as you are enrolled in the program. The privacy policy that applies to this personal information can be found at https://siliqsavings.com/docs/NOPP.pdf.

Indication and Important Safety Information for SILIQ (brodalumab) Injection


What is SILIQ?
SILIQ™ injection is a prescription medicine used to treat adults with moderate to severe plaque psoriasis:

It is not known if SILIQ is safe and effective in children.

What is the most important information I should know about SILIQ?

Suicidal thoughts or behavior: Some patients taking SILIQ have had suicidal thoughts or ended their own lives. This risk is higher if you have a history of suicidal thoughts or depression. It is not known if SILIQ causes these thoughts or actions. Get medical help right away if you or a family member notices that you have any of the following symptoms:

Your healthcare provider will give you a SILIQ patient/wallet card about symptoms that need medical attention right away. Carry the card with you during treatment with SILIQ and show it to all of your healthcare providers.

Serious Infections: SILIQ may lower the ability of your immune system to fight infections and may increase your risk of infections.