Create an Account
To create your web account for the SILIQ REMS Eligibility Check website, please complete the fields below. The Username you specify must be unique within the SILIQ REMS Eligibility Check website. Once you have submitted this form you will be logged into the website. All fields below are required unless otherwise indicated.
To create your web account for the SILIQ REMS Program, please complete the fields below. The Username you specify must be unique within the SILIQ REMS Program website. Once you have submitted this form you will be logged in on the website. All fields below are required unless otherwise indicated.

First Name
Last Name
Email Address
Confirm Email Address
Phone Number
Username
 
 Use Email Address as Username  
 Suggest Username
Password

Password must :

Must not include three consecutive identical characters
Must not be the same as the username
Confirm Password
 
Cancel