Novo NordiskResponse Program

Novo Nordisk

Response Program

The Novo Nordisk Response Program is designed for newcomers to Canada who do not have drug insurance and need assistance affording their insulin(s) and needles.

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Program Summary:

The Novo Nordisk Response Program supplies patients with select Novo Nordisk insulin(s) and needles for up to 120 days from the date that the program benefit card is activated.*

Program Materials:

Please use this form to request program benefit cards.

Additional Information:

For additional program information and an up-to-date list of insulin products and needles included in this program, visit NNRP.ca.

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*Products included in this program are at the sole discretion of Novo Nordisk Canada Inc. and are subject to change without prior notice. If private or public drug insurance is acquired within 120 days of activating the Novo Nordisk Response Program, all program benefits are terminated.

This program may change or end at Novo Nordisk's discretion.

Novo Nordisk Canada Inc.

101-2476 Argentia Road

Mississauga, Ontario L5N 6M1

Phone: +1 905 629 4222

Phone (Toll-free): +1 800 465 4334

Fax: +1 905 629 8662

Fax (Toll-free): +1 844 465 2225

www.novonordisk.ca

IMPORTANT:

This form is intended to be completed by or on behalf of healthcare professionals and organizations assisting with Canada's immigration relief efforts.

This request form is NOT intended for patients. If you are a patient, request that your healthcare professional or clinic request a card on your behalf.

Contact Information

Include the full contact information for the person to receive Novo Nordisk Response Program materials.

Contact Type*

Please select which 'Contact Type' best describes you or your organization.

Select

Clinic, Pharmacy and/or Organization Name*

First Name*

Last Name*

Clinic / Pharmacy Address - Line 1*

Clinic / Pharmacy Address - Line 2

City*

Province*

Select

Clinic / Pharmacy Postal Code*

Clinic or Pharmacy Telephone Number*

This telephone number must be the telephone number for the clinic or pharmacy you are associated with. It will be used to verify that this request came from a healthcare professional.

Phone

Email Address:*

Benefit Card Preference

Program Cards (Paper Tear Sheets) - Please allow for 1-2 weeks for delivery

e-Program Cards (PDF format)

Consent for Electronic Messages

I consent to Novo Nordisk Canada Inc. sending me electronic messages for the express purpose of providing information and updates directly relating to the provision of the services for the Novo Nordisk Response Program.

Novo Nordisk Canada Inc. will not use your personal data for purposes other than to communicate about the Novo Nordisk Response Program. Your data will not be sold, rented, leased or given away to any third party.

You may withdraw your consent at any time. Refer to Novo Nordisk Canada Inc.'s privacy policy or contact us if you have any questions.

Benefit cards cannot be provided to patients directly.

This form is intended to be completed by or on behalf of healthcare professionals and organizations assisting with Canada's immigration relief efforts.

This form is NOT intended for patients.

Please ask that your healthcare professional or immigration relief support personnel submit a request for a Novo Nordisk Response Program benefit card on you behalf.

For more information, please visit: www.NNRP.ca.

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