Medication consent

Informed Consent for Treatment with Benlysta (belimumab)

Informed consent for treatment with Benlysta.

About this form

Benlysta (belimumab) is approved for adult patients with active, autoantibody-positive systemic lupus erythematosus (SLE) and lupus nephritis. It works by blocking B-lymphocyte stimulator (BLyS), reducing the autoimmune activity that drives lupus.

!Increased risk of serious infections, including opportunistic infections.
!Possible association with depression and suicidal thoughts — please report any mood changes immediately.
!Rare reports of progressive multifocal leukoencephalopathy (PML).
!Infusion reactions and hypersensitivity, including delayed reactions.

Progress

Benefits

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

Reduces lupus disease activity and may decrease the need for high-dose steroids.Demonstrated benefit in patients with active SLE and lupus nephritis.

Common side effects

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

Nausea & diarrheaFeverMigraine / headacheInjection or infusion reactions

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 Benlysta (belimumab).

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

Trouble with the form?

Call our office and we'll either walk you through it or send a paper version.

Call (916) 677-4744 ← All forms