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?
Very good
Good
Acceptable
Poor
Very poor
*2. How satisfied are you with your treatment/clearance within your first 4 weeks on BIMZELX?
Extremely satisfied
Very satisfied
Satisfied
Slightly unsatisfied
Unsatisfied
*3. How clear is your skin compared to when you started?
Completely clear
Clear
Somewhat clear
Minimal clearance
No clearance
*4. What emotions are you feeling after 4 weeks of treatment? Click all that apply.
Gratitude
Relieved
Doubtful
Confident
Neutral/Expectations met
Discouraged
Hopeful
Overwhelmed
None of the above
Please explain your selection (Optional)
*5. Do you agree or disagree with the following statement: BIMZELX delivered fast results
Strongly agree
Slightly disagree
Agree
Disagree
Slightly agree
Strongly disagree
Neutral
*6. Do you agree or disagree with the following statement: BIMZELX has more convenient dosing than past therapies:
Strongly agree
Slightly disagree
Agree
Disagree
Slightly agree
Strongly disagree
Neutral
This is my first treatment experience
Please explain your selection (Optional)
*7. Using a letter grade, what is your overall rating for/opinion of BIMZELX?
A - Excellent
B - Very good
C - Average/good
D - Below average
F - Fail/poor
*8. Do you agree or disagree with this statement: I’m happy I switched to/started BIMZELX
Strongly agree
Slightly disagree
Agree
Disagree
Slightly agree
Strongly disagree
Neutral
This is my first treatment experience
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:
Suicidal thoughts and behavior have happened in some people treated with BIMZELX. Get medical help right away or call the National Suicide and Crisis
Lifeline at 988 if you, your caregiver or your family member notice in you any of the following symptoms:
new or worsening depression or anxiety
thoughts of suicide, dying, or hurting yourself
changes in behavior or mood
acting on dangerous impulses
attempt to commit suicide
Infections. BIMZELX is a medicine that may lower the ability of your immune system to fight infections and may increase your risk of infections.
Your healthcare provider should check you for infections and tuberculosis (TB) before starting treatment with BIMZELX.
If your healthcare provider feels you are at risk for TB, you may be treated with medicine for TB before you begin treatment with BIMZELX and during your
treatment
Your doctor should watch you closely for signs and symptoms of TB during and after treatment with BIMZELX. Do not take BIMZELX if you have an active
TB infection.
Before starting BIMZELX, tell your healthcare provider if you:
are being treated for an infection
have an infection that does not go away or that keeps coming back
have TB or have been in close contact with someone with TB
think you have an infection or have symptoms of an infection such as:
fever, sweats, or chills
muscle aches
cough
shortness of breath
shortness of breath
blood in your phlegm
weight loss
warm, red, or painful skin or sores on your body different from your psoriasis
diarrhea or stomach pain
burning when you urinate or urinating more often than normal
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).
It is not known if BIMZELX is safe and effective in children.
Before using BIMZELX, tell your healthcare provider about all of your medical conditions, including if you:
have any of the conditions or symptoms listed in the section “What is the most important information I should know about BIMZELX?”
have a history of depression, or suicidal thoughts or behavior
have liver problems
have inflammatory bowel disease (Crohn’s disease or ulcerative colitis)
have recently received or are scheduled to receive an immunization (vaccine). You should avoid receiving live vaccines during treatment with BIMZELX.
are pregnant or plan to become pregnant. It is not known if BIMZELX can harm your unborn baby.
If you become pregnant while taking BIMZELX, you are encouraged to enroll in the Pregnancy Registry, which is used to collect information about the health
of you and your baby. Talk to your healthcare provider or call 1-877-311-8972 to enroll in this registry or visit http://mothertobaby.org/pregnancy-studies/.
are breastfeeding or plan to breastfeed. It is not known if BIMZELX passes into your breast milk. Talk to your healthcare provider about the best way to feed
your baby during treatment with BIMZELX.
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?”
Elevated liver enzyme levels. Your healthcare provider will do blood tests to check your liver enzyme levels before starting treatment and during treatment
with BIMZELX. Your healthcare provider may temporarily stop or permanently stop your treatment with BIMZELX if you develop liver problems. Call your
healthcare provider right away if you develop any signs or symptoms of liver problems, including:
pain on the right side of your stomach-area
feeling very tired
loss of appetite
nausea and vomiting
itching
dark urine
light-colored stool
yellowing of your skin or the whites of your eyes
Inflammatory bowel disease. New cases of inflammatory bowel disease or “flare-ups” have happened with BIMZELX. If you have inflammatory bowel
disease (Crohn’s disease or ulcerative colitis), tell your healthcare provider if you have worsening disease symptoms during treatment with BIMZELX or
develop new or worsening signs of Crohn’s disease or ulcerative colitis.
The most common side effects of BIMZELX include:
upper respiratory tract infections
headache
Herpes Simplex infections (cold sores in or around the mouth)
small red bumps on your skin
feeling tired
fungal infections (oral thrush or infections in the mouth, throat, skin, nails, feet, or genitals)
pain, redness, or swelling at the injection site
stomach flu (gastroenteritis)
acne
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.