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Patient Consent to Participate in the Program
The Xtandi Patient Assistance Program (the “Program”) provides patients who I understand that for the purposes of the Program, my personal information,
have been prescribed Xtandi with support services, including reimbursement including the information that I provide by completing this form, and information
services, specialty pharmacy services (such as counselling & dispensing options), about my insurance, prescriptions, medical condition, and health (“Personal
and in-home nurse follow-up. Information”), will be collected, used, shared and stored as described on this form.
The Program is managed by Astellas Pharma Canada, Inc., its affiliates and I authorize my health care provider(s) and their staff and my health insurer(s), as
agents (“Astellas Canada”) and is administered by McKesson Canada Corporation applicable, to disclose my Personal Information to the Program Administrator and
(“Program Administrator”). In the event that McKesson Canada Corporation its agents for the purposes of my enrolment and participation in the Program and
ceases to be the Program Administrator, Astellas Canada may appoint a as otherwise permitted or required under law.
replacement Program Administrator to administer the Program, and I agree that
my Information may be transferred to and used by the replacement Program
Administrator in the manner described on this form, to continue to administer
the Program and provide me with support services.

Personal Information
I understand that my Personal Information will be used by the Program I understand that I have the right to revoke this consent at any time by contacting
Administrator to: the Program Administrator at 70 Wynford Dr P.O. Box 383, North York, Ontario,
• Contact me and complete my enrolment in the Program; M3C 2S7 and 1-855-982-6348. I may access my Personal Information held by the
• Provide me with support services that are part of the Program; Program Administrator and may rectify or request corrections using the contact
• Provide my caregiver, if caregiver information is specified, support services that information above. If I wish to make inquiries or complaints or have other concerns
are part of the Program; about the Program Administrator’s personal information practices, I can contact
the Program Administrator.
• Communicate with my medical insurance provider(s) to determine if I am eligible
for reimbursement; I authorize the Program Administrator to contact me in relation to these services
• Share my information, including date of birth and diagnosis, with my medical by mail, email, fax, telephone call or text message. I authorize you to leave
insurance provider(s) in order to establish insurance reimbursement; messages at the provided phone number or email address, and I understand that
• Communicate with my physician, nurse, pharmacist, or their staff, when appropriate; such messages may mention the name of Astellas Canada’ products or services,
details about my medical condition and insurance coverage and my doctor’s name.
• Coordinate fulfillment of my prescription; and
• Perform internal evaluation and assessments of the Program. I UNDERSTAND THAT:
My Personal Information may be communicated to Astellas Canada in a • By signing this form, I agree to be enrolled into the Program.
de-identified or aggregated manner (in non-personally identifiable form) and used • Participation in the Program is not required for me to receive my medication.
for the purposes of Program assessment, improvement and financial administration, • I am not required to sign this consent form. If I choose not to consent to the
for regulatory purposes, for product or program development or in order to comply collection use and disclosure of my Personal Information, I will not be able to
with applicable laws. participate in the Program.
My Personal Information may also be provided to and used by Astellas Canada • I am responsible for ensuring that I meet any requirements and conditions related
in the context of reporting any adverse drug events to Health Canada or other to public drug program enrolment (e.g. Ontario’s Trillium Drug Program) where
government agencies in and outside of Canada, or as otherwise may be required applicable.
by law. Astellas Canada may also be required to review my Program file (with my • Signing this form will not affect my medical treatment and is not a requirement for
initials only to identify me) in order to audit the Program and confirm the accuracy coverage by my insurance provider and will not affect my insurance enrolment or
eligibility for insurance benefits.
of the data collected through the Program. • My Personal Information may be transferred and stored outside of Canada.
I understand that privacy laws require the Program Administrator to protect my • I authorize my health care provider to provide the Program Administrator with this
privacy by requiring that it collect, use and disclose my Personal Information only completed form on my behalf so that a Program nurse and coordinator can contact
for the purposes described herein or as permitted or required by law. me in connection with the Program.
My Personal Information will be stored by the Program Administrator in a secure • Unless and until revoked, this consent is valid for the duration of the Program.
and confidential database, with access to the database restricted to authorized Astellas Canada reserves the right to modify, suspend or terminate the Program,
employees and agents. Safeguards are used to protect my Personal Information or any part thereof, in its sole discretion.
against unauthorized access, disclosure, copying, use or modification. I understand
that my Personal Information may be stored or processed outside of Canada. If this The Program is not intended to provide medical advice or medical diagnoses. Always seek
the advice of your physician, pharmacist or other qualified health provider if you have any
is the case, it would be subject to the laws of that country where it is stored. That health concerns. Never disregard professional medical advice or delay in seeking it because
country may have laws that require that Personal Information be disclosed to the of something you have read or other information conveyed as a result of this Program.
government under different circumstances than would Canada.

Xtandi® (enzalutamide capsules) is indicated for the treatment of patients with metastatic castration-sensitive prostate cancer (mCSPC).
Xtandi® (enzalutamide capsules) is indicated for the treatment of patients with non-metastatic castration-resistant prostate cancer (nmCRPC). Xtandi has not been studied
in patients with nmCRPC at low risk of developing metastatic disease. The benefit and risk profile in these patients is unknown.
Xtandi is indicated in the setting of medical or surgical castration for the treatment of metastatic castration-resistant prostate cancer (mCRPC) in patients who:
• Are chemotherapy-naïve with asymptomatic or mildly symptomatic disease after failure of androgen deprivation therapy.
• Have received docetaxel therapy.
Consult the Xtandi Product Monograph at https://www.astellas.com/ca/system/files/2020-06/Xtandi_PM_EN_June2020.pdf for important information relating to contraindications,
warnings, precautions, adverse reaction, interactions, dosing and conditions of clinical use. The Product Monograph is also available through Medical Information at 1-888-338-1824.

Xtandi Patient
Xtandi Patient Assistance Program XPAP Assistance Program
70 Wynford Dr., P.O. Box 383, North York, ON, M3C 2S7 Surround yourself with suppor t
Phone: 1-855-982-6348 (1-855-Xtandi-8)
Fax: 1-855-982-6349 (1-855-Xtandi-9)
Email: info@XTANDIassistanceprogram.ca Xtandi® is a registered trademark of Astellas Pharma Inc. © 2020 Astellas Pharma Canada, Inc. All rights reserved.
076-5095-PM-EN