Ubrelvy Challenge Campaign Signup

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Thankyou page URL [Hidden]

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Step 1 of 2

Please answer the following questions:

Required

[Hidden]Campaign Master ID

Are you currently prescribed an oral triptan?

Yes

Do you live in the United States, including Puerto Rico?

Yes

Do you have commercial prescription drug insurance? (If you receive prescription reimbursement under any federal, state, or government-funded insurance programs, for example, Medicare [including Part D], Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs. select "No.")

Yes

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Step 2 of 2

All fields required unless noted otherwise.

First name

Last name

Date of birth (Note: Participants must be 18 years old.)

ZIP code

Gender

Female

Male

Email Address missing or SourceId invalid in the request object

Email Does not Exist

Please enter a valid email address

Email is Invalid

Email address (See email consent below.)

Your email will be used only to provide assistance with this program.

Mobile phone (Optional - see text messaging consent below.)

Your phone number will be used only to provide assistance with this program.

Drug Benefit Enrollment [Hidden]

Please check the box below if you would like to enroll in our text messaging program.

I consent to receive UBRELVY automated and recurring text messages from “AbbVie”, including services updates, medication reminders and marketing messages to the above mobile number. Message and data rates may apply. I am not required to consent as a condition of receiving goods or services. I can reply HELP for help. I can reply STOP to opt out at any time. View Privacy Notice and Mobile Terms & Conditions here.

Please check the box below if you would like to receive email communications from AbbVie related to UBRELVY, the UBRELVY Challenge, and the UBRELVY Complete Savings Program, including site updates, patient education, as well as other AbbVie products and services.

I consent to the collection, use, and disclosure of my health-related personal data and/or precise geolocation personal data to receive communications from AbbVie regarding its products, programs, services, clinical trials, research opportunities and for online targeted advertising, as further described in the “How we may use Personal Data,” “How we disclose Personal Data,” and “Cookies and similar tracking and data collection technologies” sections of our Privacy Notice. My consent is required to process sensitive personal data under certain privacy laws, and I have the right to withdraw my consent by visiting “Your Privacy Choices” on AbbVie's website.

Privacy Notice: AbbVie may collect your personal data through your online and offline interactions with us, including your contact data, geolocation and health-related data. We may also collect your online usage data automatically through cookies and similar technologies. We use this information for several purposes, such as to provide you with, administer, and improve our programs, services and products, customize your experiences, and for research and analytics. We retain your personal data for as long as necessary to deliver you ads based on your interests inferred from your activity across other unaffiliated sites and services (“online targeted advertising”) and for website analytics. To opt out of the use or disclosure of your personal data for online targeting advertising or for website analytics, go to Your Privacy Choices on our website. For more information on the personal data categories we collect, the purposes for their collection, disclosures to third parties, and data retention, visit our Privacy Notice.

Consent to process my sensitive personal information: Through my submission of this Registration Form, I consent to the collection, use, and disclosure of my personal health data, as described in the Privacy Notice above and in AbbVie’s Privacy Notice in the “How we may use Personal Data” section. My consent is required to process sensitive personal data under certain privacy laws, and I have the right to withdraw my consent by visiting “Your Privacy Choices” on AbbVie’s website.

Please check the box below if you agree to the following:

• I certify that I am not enrolled in a government-sponsored prescription drug benefit program, such as Medicare, Medicaid, or any private indemnity or HMO insurance plan that reimburses me for the entire cost of my prescription drugs.

• I certify that if at any time I begin receiving prescription drug coverage under any federal-, state-, or government-funded healthcare program, I will no longer be eligible for this offer and must cease participation.

• I certify that I have read and accept the UBRELVY Challenge Offer Terms and Conditions.

• I certify that all of the information I have provided is true and accurate.

I agree.

Source Id

Please provide appropriate value in each field's default value property as per Analytics Tech Specs

Form Name:

Form Category:

Account Management, Contact, Interactions, Quiz, Registration, Services

Form Sub-Category:

Password Resets, Login, Profile, Representative, Contact Us, Polls, Social Share, Doctor Discussion Guide, Dosing Guide, Symptom Checker, Knowledge Assessment, Event, More Info, Sign Up, Saving Card, Benefit Verification, Benefit Enrollments, Medical Exception, Injection Form, Share a Story

Form MVA Name:

Form MVA Type:

Download, Form, Link, Share, Tool, Video

Form MVA Tier:

Form MVA Category:

Savings Card, Insurance, Symptom Journal, Test Score Tracker, Condition Information, Doctor Discussion Guide, Dosing Information, Enrollment Form, Flashcard, Medical Exception, Patient Counseling Guide, Savings Card, Symptom Journal, Doctor Discussion Guide, Doctor Search, Dosage Calculator, Enroll, Med Reminders, Quick Poll, Resource Request, Symptom Quiz, UGC Submission, Contact Rep, Savings Card, Social Share, App Store, More Info, Patient Resources, Share Information, Share Results, Submit a Story, Assessment Tool, Benefits Verification, Carousel, Initiation, Myth versus Fact, Workaround Quiz, Formulary Tool, Image Expand, Medical Exception, Q And A, Slider, Administration Instructions, Condition Information, Insurance, Inventory, Mechanism of Action, Patient Story, Product Overview, Program Overview, Injection Training, Other

Form PII Field Names for Masking:

Form Analytics Payload:

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