Patient Enrolment Form for the VICTORY® Program Services

Instructions

How it works?

The VICTORY® Program is sponsored by Amgen Canada and administered by a third-party patient support company, consisting of patient-focused access specialists. VICTORY® Program Reimbursement Specialists will help determine if a patient has a private or public drug plan, and whether they are eligible to receive support from Amgen Canada. Once eligibility has been confirmed, patients will receive their medication.

How to enrol?

Once your physician has prescribed you Vectibix® (panitumumab) or Kyprolis® (carfilzomib), you can enrol by filling out this form. Upon completion, VICTORY® will send you a confirmation and reach out by email.

Need help?

The VICTORY® Program support line (1-888-706-4717) provides you and your caregiver access to dedicated support personnel who are knowledgeable about Amgen Canada oncology- and hematology-related medications as well as the reimbursement process.

Hours of operation are as follows:
Open Monday to Friday:

  • Newfoundland Standard Time: 9:30 a.m. to 9:30 p.m.
  • Atlantic Standard Time: 9:00 a.m. to 9:00 p.m.
  • Eastern Standard Time: 8:00 a.m. to 8:00 p.m.
  • Central Standard Time: 7:00 a.m. to 7:00 p.m.
  • Mountain Standard Time: 6:00 a.m. to 6:00 p.m.
  • Pacific Standard Time: 5:00 a.m. to 5:00 p.m.

Choose your VICTORY® Program service:

Select the brand you’ve been prescribed:

  • Vectibix® (panitumumab)
  • Kyprolis® (carfilzomib)

Prescriber information:

Patient information:

Provide an alternate contact who speaks English/French for purposes relating to your enrolment (optional)

Consent:

I acknowledge that I have read and understand the legal information (as described in full at the bottom of this page) and consent to the collection, use, and disclosure of my personal information, including personal health information, by McKesson, Amgen, and Amgen’s agents and service providers. I further consent to being contacted from time to time by McKesson, Amgen, or Amgen’s agents and service providers for the above-noted purposes.

Legal information:

Prescriber information:

Patient information:

Provide an alternate contact who speaks English/French for purposes relating to your enrolment (optional)

Consent:

I acknowledge that I have read and understand the legal information (as described in full at the bottom of this page) and consent to the collection, use, and disclosure of my personal information, including personal health information, by McKesson, Amgen, and Amgen’s agents and service providers. I further consent to being contacted from time to time by McKesson, Amgen, or Amgen’s agents and service providers for the above-noted purposes.

Legal information: