Thank you for enrolling in the BIMZELX Xperience. It’s time to share your treatment progress with your healthcare provider.

Please answer the following eight questions. Your feedback will be electronically delivered to your healthcare provider when you click “Submit.” Your voice matters, so be sure to discuss your BIMZELX feedback with your provider at your next visit.

Thank you!

Fields marked with an asterisk (*) are required.
*1. How would you rate the skin improvement you’ve seen over the past 4 weeks?
*2. How satisfied are you with your treatment/clearance within your first 4 weeks on BIMZELX?
*3. How clear is your skin compared to when you started?
*4. What emotions are you feeling after 4 weeks of treatment? Click all that apply.

Please explain your selection (Optional)

*5. Do you agree or disagree with the following statement: BIMZELX delivered fast results
*6. Do you agree or disagree with the following statement: BIMZELX has more convenient dosing than past therapies:

Please explain your selection (Optional)

*7. Using a letter grade, what is your overall rating for/opinion of BIMZELX?
*8. Do you agree or disagree with this statement: I’m happy I switched to/started BIMZELX

Please explain your selection (Optional)

* Your survey will be complete after you read and acknowledge the terms below and click “Submit.”
By selecting this Patient Authorization to Use/Disclose Health Information box (“Authorization”), I hereby authorize my physicians to disclose information related to my medical condition and treatment (including prescription information), my name, and my email address to UCB, Inc., and its agents, service providers, contractors, and representatives (together, “UCB”), so that UCB may: (i) enroll me in, and contact me about, UCB medication support programs and/or related market research, including BIMZELX Xperience; (ii) provide me with educational materials, information, and services related to UCB medications; (iii) verify, investigate, assist with, and coordinate my coverage for a UCB medication with my Insurers and Providers; (iv) conduct market analyses or other commercial activity, including aggregating my Protected Health Information with other data for such analyses; (v) assist with analysis related to quality, efficacy, and safety for UCB medication; (vi) de-identify my Protected Health Information for use for any purpose under applicable law; and (vii) send marketing communications to me, which may be delivered under the communication terms described below if I additionally agree to those terms.

If you have any questions or concerns about BIMZELX treatment or your psoriasis, please contact your healthcare provider.

IMPORTANT SAFETY INFORMATION

What is the most important information I should know about BIMZELX®

BIMZELX is a medicine that affects your immune system. BIMZELX may increase your risk of having serious side effects, including:

Before starting BIMZELX, tell your healthcare provider if you:

After starting BIMZELX, call your healthcare provider right away if you have any of the signs of infection listed above. Do not use BIMZELX if you have any signs of infection unless you are instructed to by your healthcare provider. See “What are the possible side effects of BIMZELX?” for more information about side effects.

What is BIMZELX?

BIMZELX is a prescription medicine used to treat adults with moderate to severe plaque psoriasis who may benefit from taking injections or pills (systemic therapy) or treatment using ultraviolet light alone or with pills (phototherapy).

Before using BIMZELX, tell your healthcare provider about all of your medical conditions, including if you:

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.

What are the possible side effects of BIMZELX?

BIMZELX may cause serious side effects. See “What is important information I should know about BIMZELX?” The most common side effects of BIMZELX include:

These are not all of the possible side effects of BIMZELX. Call your doctor for medical advice about side effects.

Use BIMZELX exactly as your doctor tells you to use it.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.