Repatha Ready" Universal Patient Authorization Form Fax this form back with the patient's demographic information and signature to: 1-855-REPAT HA (1-855-737-2842). Repatha Ready 0 Repatha. (evolocumab) Patient Information Piront'',me' Pretend Phone( ) Street Addres c• EmailAddress: City':_ St≥te': 7ip• Date of Birth*: Social Security M. Prescriber Information Office Contact kg i.f ri Ng IMW Off ce Street Address': Vat Ritre.1 -47X S/. da 4 rA State: Al /Zit. /0 °I ? Email Address: ity.: Prescriber Name': RtAl 7 SHIMMY Telephone':( Wally 642COOLOr4 / Fat( 24? 374 - 3190 ofta Name 417. \UAW/ year' icrettatdir Prescriber NFI il*: Repatha Ready' Program Privacy Notice and Authorization In accordance with my signature below, I understand and consent to Amgen contacting me using the contact information provided in this form to enroll me in, operate, and administer Amgen patient support services and/or programs as described in the Patient Privacy Authorization other than promotional communications by telephone or SMS/text (to which I can separately opt-in below). I understand that the operation and administration of certain of these services and/or programs may require that Amgen contact me by telephone or SMS/text. My preferred methods) of contact 0 Email LI Phone 0 Mail 0 SMS/text (standard text message charges may apply from your wireless provider) 0 In addition to the above consent, I understand that by checking this box and signing below, I consent to Amgen calling and texting me at the phone number(s) I have provided with promotional communications relating to Amgen products and services and/or my condition or treatment. Amgen may use automatic dialing machines or artificial or prerecorded messages to contact me and may leave a voicemail or text message (standard text messaging rates may apply). I understand that I am not required to provide this consent as a condition of purchasing any goods or services. My si