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Access to americanmigrainefoundation.org is not intended to provide medical advice or a referral to a particular physician;
Patients should discuss with their physician their experience with the patient’s medical condition and should then determine if the physician is qualified to perform the procedure;
Patients should discuss the risks and benefits of any procedure with their physician;
americanmigrainefoundation.org is an independent entity, and not affiliated with, or an agent of, Amgen Inc.
Amgen Inc. has not entered into any agreement with any doctor affiliated with americanmigrainefoundation.org to render any treatment or care to any patient, and has not evaluated the credentials, experience or expertise of any physician affiliated with, or referred through, americanmigrainefoundation.org.
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*First Name

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*Have you been diagnosed with migraine by a doctor?

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*How many days per month are you typically impacted by migraine?

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*Are you currently using any preventive migraine treatments or have you used any in the last 5 years?

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When it comes to migraine, who do you rely on most for information/support?

The Aimovig AimAlly™ 90-Day Start Program is a simple way to get the resources and support you need to navigate your first 3 months on Aimovig, all in one place.

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Consents

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Consent to Health Data Processing for Aimovig AimAlly™ 90-Day Start

I consent to Amgen processing my Health Data for the following purposes:

To enroll me and manage my participation in Amgen's Aimovig AimAlly™ 90-Day Start program, which includes activities related to my condition or treatment (for example, co-pay card programs, payer medication coverage verification, nurse partner support, disease management support), and to manage Amgen’s products, services, and programs related to my condition or treatment.

Amgen uses the following when it administers the Aimovig AimAlly™ 90-Day Start program:

Health Data – my name (and the name of my caregiver if applicable), gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that my consent to processing is required for me to participate in the Aimovig AimAlly™ 90-Day Start program. I also understand that Amgen will not sell my Health Data to third parties, but Amgen may disclose my Health Data to Amgen’s data processors, contractors, and business partners for Amgen’s business purposes related to the Aimovig AimAlly™ 90-Day Start program. I understand that Amgen may use my Health Data to contact me by mail, email, telephone, or text for the above purposes. I also understand that if I do not consent to the use of my Health Data for the above purposes, I will not be able to participate in the Aimovig AimAlly™ 90-Day Start program. Finally, I understand that I may withdraw my consent to processing my Health Data for the above purposes at any time using one of the methods listed in the Additional Disclosures section below and that if I withdraw my consent, I will no longer be able to participate in the Aimovig AimAlly™ 90-Day Start program.

I consent to the collection, processing, and disclosure of my Health Data for the above purposes I do not consent to the collection, processing, or disclosure of my Health Data for the above purposes By selecting “I do not consent to the collection, processing, or disclosure of my Health Data for the above purposes,” you will not be able to continue enrolling in Aimovig AimAlly™ 90-Day Start By selecting “I do not consent to the collection, processing, or disclosure of my Health Data for the above purposes,” you will not be able to continue enrolling in Aimovig AimAlly™ 90-Day Start

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Consent to Health Data Collection & Processing for Marketing Purposes

I consent to Amgen collecting and processing my Health Data for the following purposes:

To conduct marketing activities, including market research activities, and to communicate with me regarding products and services that may be of interest to me.

Amgen uses the following for marketing purposes:

Health Data – my name, gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that Amgen is seeking my consent to collect and process my Health Data to market products and services to me and that I do not have to give consent to the collection and processing of my Health Data for marketing purposes in order to participate in the Aimovig AimAlly™ 90-Day Start program. I also understand that Amgen will not sell my Health Data to third parties. If I consent to the collection and processing of my Health Data for marketing purposes, I agree that Amgen may contact me for marketing purposes. Finally, I understand that I may withdraw my consent to the collection and processing of my Health Data for marketing purposes at any time using one of the methods listed in the Additional Disclosures section below.

I consent to the collection and processing of my Health Data for marketing purposes I do not consent to the collection and processing of my Health Data for marketing purposes If you do not consent to the collection and processing of your health data for marketing purposes, you will not be able to receive marketing communications from Amgen. If you want to receive marketing communications from Amgen, select “I consent to the collection and processing of my Health Data for marketing purposes” If you do not consent to the collection and processing of your health data for marketing purposes, you will not be able to receive marketing communications from Amgen. If you want to receive marketing communications from Amgen, select “I consent to the collection and processing of my Health Data for marketing purposes”

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Consent to Health Data Disclosure for Marketing Purposes

I consent to Amgen disclosing my Health Data to its data processors, contractors, and business partners for the following purposes:

To conduct marketing activities, including market research activities, and to communicate with me regarding products and services that may be of interest to me.

If I provide my consent, Amgen will disclose the following for such purposes:

Health Data – my name, gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that Amgen is seeking my consent to disclose my Health Data to its data processors, contractors, and business partners to market products and services to me and that I do not have to give consent to disclosure of my Health Data for marketing purposes in order to participate in Aimovig AimAlly™ 90-Day Start. I also understand that Amgen will not sell my Health Data to third parties. Finally, I understand that I may withdraw my consent to the disclosure of my Health Data for marketing purposes at any time using one of the methods listed in the Additional Disclosures section below.

I consent to the disclosure of my Health Data for marketing purposes I do not consent to the disclosure of my Health Data for marketing purposes If you do not consent to the disclosure of your health data for marketing purposes, you will not be able to receive marketing communications from Amgen. If you want to receive marketing communications from Amgen, select “I consent to the disclosure of my Health Data for marketing purposes” If you do not consent to the disclosure of your health data for marketing purposes, you will not be able to receive marketing communications from Amgen. If you want to receive marketing communications from Amgen, select “I consent to the disclosure of my Health Data for marketing purposes”

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Consent to Health Data Collection & Processing for Marketing Purposes

I consent to Amgen collecting and processing my Health Data for the following purposes:

To conduct marketing activities, including market research activities, and to communicate with me regarding products and services that may be of interest to me.

Amgen uses the following for marketing purposes:

Health Data – my name, gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that Amgen is seeking my consent to collect and process my Health Data to market products and services to me and that I do not have to give consent to the collection and processing of my Health Data for marketing purposes. I also understand that Amgen will not sell my Health Data to third parties. If I consent to the collection and processing of my Health Data for marketing purposes, I agree that Amgen may contact me for marketing purposes. Finally, I understand that I may withdraw my consent to the collection and processing of my Health Data for marketing purposes at any time using the method listed in the Additional Disclosures section below.

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Consent to Health Data Disclosure for Marketing Purposes

I consent to Amgen disclosing my Health Data to its data processors, contractors, and business partners for the following purposes:

To conduct marketing activities, including market research activities, and to communicate with me regarding products and services that may be of interest to me.

If I provide my consent, Amgen will disclose the following for such purposes:

Health Data – my name, gender, date of birth, contact information and information relating to my health condition or treatment.

I understand that Amgen is seeking my consent to disclose my Health Data to its data processors, contractors, and business partners to market products and services to me and that I do not have to give consent to disclosure of my Health Data for marketing purposes. I also understand that Amgen will not sell my Health Data to third parties. Finally, I understand that I may withdraw my consent to the disclosure of my Health Data for marketing purposes at any time using the method listed in the Additional Disclosures section below.

Additional Disclosures

I understand that participation in the Aimovig AimAlly™ 90-Day Start program and, if I have consented, receipt of marketing communications are optional services at no cost to me. The consent(s) above in no way affects my right to obtain any medications and I do not have to provide consent to be able to receive any medications. To obtain a copy of the consent(s) above or to withdraw my consent to collection, processing, and/or disclosure of my Health Data for any of the above purposes to which I have consented, I can contact Amgen by visiting www.amgen.com/DataSubjectRights or calling 1-833-246-6844. For more information about Amgen’s privacy practices, Amgen’s Privacy Statement can be found at http://www.amgen.com/privacy.

Additional Disclosures

I understand that receipt of marketing communications are optional services at no cost to me. The consent(s) above in no way affects my right to obtain any medications and I do not have to provide consent to be able to receive any medications. To obtain a copy of the consent(s) above or to withdraw my consent to collection, processing, and/or disclosure of my Health Data for any of the above purposes to which I have consented, I can contact Amgen by visiting www.amgen.com/DataSubjectRights. For more information about Amgen’s privacy practices, Amgen’s Privacy Statement can be found at http://www.amgen.com/privacy.

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Additional Disclosures

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