TouchPoint - TouchPoint™ patient enrolment form

Patient enrolment form

The TouchPoint^™ Patient Support Program ("Program") has been developed specifically for people prescribed Taltz^® (ixekizumab (rch)) in Australia. To join, confirm below that you have been prescribed Taltz, enter your details, agree to the terms and conditions below, then click the Submit button.

I have been prescribed Taltz in Australia for the treatment of moderate to severe plaque psoriasis or severe psoriatic arthritis in accordance with the applicable approved indication.

Title

First name^*

Surname^*

Home address

Suburb

State

Postcode

Contact number^*

Alternative contact number

Mobile number

Patient email

Date of birth

Gender

Female Male Prefer not to specify

Prescriber first name^*

Prescriber surname^*

Prescriber contact number

I consent to enrol in the Taltz TouchPoint^™ Program.
I understand that I will be contacted by a Touchpoint^™ nurse to deliver support services.
I consent to the Taltz TouchPoint^™ nurses contacting my prescribing doctor where necessary to deliver program services.
I have read, understand and agree to the Privacy Statement.
I understand I am free to opt out of the Touchpoint^™ Program or any of its services anytime.

I consent to anonymised population level data (meaning information not disclosing my identity) that is collected during my participation in the Touchpoint^™ Program being used for the purpose of Lilly marketing communication.
I consent to anonymised population level data (meaning information not disclosing my identity) that is collected during my participation in the Touchpoint^™ Program being used for the purpose of medical research, including via publication in medical journal and/or presentations at clinical meetings.

For technical support, please contact the TouchPoint^™ Program Care Coordinators on 1800 4 TALTZ (1800 482 589), Mon – Fri, 9am – 5pm (AEST).

Thank you for registering. You will be contacted shortly.

Patient enrolment form