Medication consent

Informed Consent for Treatment with Actemra (tocilizumab)

Informed consent for treatment with Actemra.

About this form

Actemra (tocilizumab) is used to treat moderately to severely active rheumatoid arthritis and certain other inflammatory conditions. It works by blocking the action of interleukin-6 (IL-6), a protein involved in inflammation, to reduce joint pain and swelling.

!Actemra decreases immune system function (immunosuppression), which can result in serious infections including bacterial, viral, fungal, or other opportunistic infections.
!Tuberculosis (TB) skin testing is required prior to treatment. Patients with HIV or hepatitis B may not be candidates.
!Patients in geographic areas where fungal infections are common may be at higher risk.
!Possible increased risk of cancer, particularly lymphoma.
!Rare but serious risks include gastrointestinal perforation, nervous system problems, infusion / allergic reactions, elevated cholesterol, hepatitis B reactivation, liver damage, and abnormalities in blood counts.

Progress

Benefits

I understand that the potential benefits of this treatment include: *

FDA-approved for moderately to severely active rheumatoid arthritis when other therapies (including TNF blockers) have not provided adequate response.Reduces inflammation, pain and swelling — and can slow joint damage progression.

Common side effects

I have been informed of the most common side effects, which include: *

Upper respiratory infectionsHeadacheHigh blood pressureAbnormal liver function tests

Acknowledgements

I have had the opportunity to discuss this treatment with my physician. *

Yes — I have had this opportunity

All of my questions have been answered to my satisfaction. *

Yes — my questions have been answered

I understand my financial responsibility for this treatment. *

Yes — I understand

Any additional questions or notes for our team

Sign & submit

Patient name *Date of birth *Email address *Patient signature (type your full name) *Date *

Acknowledgement. I certify that I have read and understood this consent form, that I have had the opportunity to discuss it with my physician, and that I agree to receive treatment with Actemra (tocilizumab).

Submitting transmits this form securely to our office. For urgent medical issues please call our office or 911.

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