VALEANT Patient Assistance Program Application

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V1 Patient Assistance Program Application fiffffifl˙ffiˇff˘˘flffiffˆ ˙ˇ fi ff Page 2 of 4 To be completed by the Patient Patient Authorization and Certification (Patient must read and sign below) I hereby consent to allow Valeant Pharmaceuticals, and its affiliates, agents, and contractors, including the administrator of

  Programs, Patients, Assistance, Valeant patient assistance program, Valeant