CANADIAN THALOMID® ACCESS PROGRAM (CANTAP) REGISTRATION FORM

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					                   CANADIAN THALOMID® ACCESS PROGRAM (CANTAP)

                                            REGISTRATION FORM

Welcome to CANTAP. By completing the form below and reviewing the Code of Ethics and Applicant Declaration, you
                                                                           ®
enable us to review your request for compassionate supply of THALOMID . Please clearly print responses for all items on
the form. If an item does not apply, please write N/A in the space provided.


                     Please FAX the SIGNED and completed pages of this form to 1-888-311-6817


1.   PATIENT INFORMATION

_________________________________________________________________________________________________
Surname                           First Name                 Middle Name/Initial
_________________________________________________________________________________________________
Street Address
_________________________________________________________________________(_______)_______________
City                       Province           Postal Code                    Telephone Number
_______________________                                              ________________________________
Date of Birth (DD/MM/YYYY)        Gender:    Female     Male         Health Card Number

Do you receive social assistance benefits or other benefits?         No    Yes (? if yes, please specify) _________________




2.   PHYSICIAN / PRESCRIBING INFORMATION


_________________________________________________________________________
Physician Name
_________________________________________________________________________________________________
Street Address
_________________________________________________________________________________________________
City                                          Province                   Postal Code
_(_______)________________      _(_______)________________       ________________________________
Telephone Number                Fax Number                       Name of office contact regarding this request

Diagnosis: __________________________________________________________________________________________________


THALOMID® Dosage: _____________________________________________________________________________________




                                                            CANTAP
                                     169 The Donway, PO Box #383 Don Mills, ON M3C 2S7
                                           Tel : 1-888-611-6817 Fax : 1-888-311-6817
          Page 2                                            Patient Name:______________________________



3. CODE OF ETHICS

Celgene Corporation is the sponsor of CANTAP. CANTAP is administered according to the following Code of Ethics.

Our Commitment: Our goal is to provide callers and patients with the most unbiased, informed and comprehensive
information as possible. We are not a substitute for your doctor, nurse, or other healthcare professional. Our role is to
objectively assess your eligibility request for compassionate use of THALOMID®, and if eligible, to supply you with
THALOMID® free of charge.

Confidentiality: CANTAP endeavours to ensure patient confidentiality. Patient information will not be released without the
express consent of patients, and then only under the conditions agreed to on the copy of the consent form that you have
signed.

Safekeeping of Records: Patient records or information collected on behalf of CANTAP are not accessible to parties
outside of our program unless expressly authorized by you in writing. Security and safeguards appropriate to the
sensitivity of the information collected protect all personal information.

Acting on Patient’s Behalf: Best efforts are made on behalf of patients. All patient and health professional calls are
answered according to professionally developed guidelines and protocols. In cases where CANTAP acts as an agent for
patients, no patient information will be released without the patient’s prior written consent.




4. APPLICANT DECLARATION

I verify that the information that is provided in this application is complete and accurate. I understand that Celgene
Corporation reserves the right at any time, and without notice, to modify the application form or modify or discontinue the
Program.

In order to ensure the accuracy and completeness of this application, I hereby authorize and instruct CANTAP to obtain
any medical and personal information relating to my enrolment in CANTAP, from my prescribing physician(s),
pharmacist(s) and any other health care provider that may possess the requisite information.

I understand that all the information recorded in CANTAP will be treated as strictly confidential in compliance with federal
and provincial privacy legislation and as described below.

I hereby consent to the collection of this information by Celgene Corporation or its designated agents. I hereby consent to
the use of this information by Celgene Corporation and its designated agents for the purpose of shipping drugs to my
physician and to facilitate the administration of the CANTAP program. I hereby consent to the disclosure of the information
collected to organizations administering CANTAP and to Celgene Corporation and its affiliates for the purposes of
regulatory reporting requirements, program monitoring and evaluation and to the collection, use and disclosure of the
information as permitted or required by law.



________________________________________                          ________________________________
Signature of Patient/Agent                                        Date of Signature


                                                                                   ®
If the person signing is not the patient/registrant who will be receiving THALOMID , please indicate whether you have the
authority to consent on the patient/registrants behalf.        Yes            No

.




                                                            CANTAP
                                     169 The Donway, PO Box #383 Don Mills, ON M3C 2S7
                                           Tel : 1-866-611-6817 Fax : 1-866-311-6817