How to apply

a) By fax

Download the enrolment form and fill it out.
Fax the completed form to 1‑833‑884‑5608.
Complete the VICTORY^® checklistOpens in new window so you can be prepared when a VICTORY^® Program Reimbursement Specialist calls you within one business day of your contacting VICTORY^®.

Download enrolment form here

You will need to consult your doctor to find out what type of medication has been prescribed to you before completing the form.

Patient enrolment form

Use this form if you have been prescribed one of these oncology or hematology drugs: Aranesp^®, BLINCYTO^®, KANJINTI^®, KYPROLIS^®, LUMAKRAS^TM, MVASI^®, Neulasta^®, NEUPOGEN^®, Nplate^®, Vectibix^®, or XGEVA^®.

Download enrolment form

Patient demographics
Name:	{{Name}}
Adress:	{{Address}}
Primary phone no.:	{{PrimaryPhone}}
Secondary phone no. (optional):	{{SecondaryPhone}}
Date of birth:	{{DOB}}
Hospital:	{{Hospital}}
Prescribing physician:	{{PrescribePhysician}}
Other healthcare contact (social worker, RN):	{{OtherHealthSocialContact}}
Other healthcare contact phone no.:	{{OtherHealthcarePhone}}
Pharmacy name:	{{PharmacyName}}
Pharmacy phone no.:	{{PharmacyPhone}}
Prescribed Rx:	{{PrescribedRX}}
Prescription start date:	{{PrescriptionStartData}}

Private insurance details:
Insurance company:	{{InsuranceComp}}
Plan/policy no.:	{{PolicyNo}}
ID certificate no.:	{{certificateID}}

Provincial insurance details:
Drug card name:	{{DrugCardName}}
Provincial insurance details:	{{ProvincialInsurance}}

How to enrol

a) By fax

b) By phone

Patient demographics:

Private insurance details:

Provincial insurance details:

How to enrol

Step 1

Step 2

a) By fax

b) By phone

Step 3

Step 4

Patient enrolment form

Checklist

Patient checklist

Patient demographics:

Private insurance details:

Provincial insurance details: