Participating Hospital Certification Form

Participating Hospital Certification Form ATTENTION: this Certification Form is only applicable for Free Trial Product Units of ABILIFY MAINTENA (aripiprazole). Instructions: The Authorized Representative must perform the following for the Certification Form to be considered complete: Complete all required information marked with an *. Acknowledge all Terms and conditions by initialing in the appropriate box. Print name and title. Sign and date. Completed forms may be sent for processing via fax to 614-652-8810 or email Participating Hospital information: Hospital Name*. Shipping Address Line 1*. Shipping Address Line 2. City*. State*. Zip*. Hospital License Number*. Hospital License Number Expiration Date*. Pharmacy information: Pharmacy License Number*. Pharmacy License Number Expiration Date*. Pharmacist information: Pharmacist License Number*. Pharmacist License Number Expiration Date*. Please see IMPORTANT SAFETY INFORMATION on pages 5 and 6. Page 1 of 6. Affiliated Prescriber information: [If there are more than three (3) prescribers affiliated to a Participating facility, please contact Cardinal Health at 1-844-735-0717 or email HCP First & Last Name*.]

Please see accompanying FULL PRESCRIBING INFORMATION, including BOXED WARNING. Page 6 of 6 IMPORTANT SAFETY INFORMATION for ABILIFY MAINTENA® (aripiprazole) (Continued) Orthostatic Hypotension: ABILIFY MAINTENA may cause orthostatic hypotension and should be used with caution in patients with known cardiovascular disease, cerebrovascular disease, or conditions …

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