Medication consent

Informed Consent for Treatment with Cimzia (certolizumab pegol)

Informed consent for treatment with Cimzia.

About this form

Cimzia (certolizumab pegol) is a TNF blocker used to treat rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, plaque psoriasis, and Crohn's disease. It reduces inflammation by blocking tumor necrosis factor (TNF).

!Serious infections including TB, fungal, viral, and bacterial infections.
!Increased risk of certain cancers, including lymphoma and skin cancer.
!Hepatitis B reactivation in chronic carriers.
!Heart failure can worsen.
!Nervous system disorders (rare).

Progress

Benefits

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

Effective for moderate-to-severe RA, PsA, AS, plaque psoriasis, and Crohn's disease.Reduces inflammation, pain, and slows joint damage.

Common side effects

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

Upper respiratory tract infectionsRashUrinary tract infectionsInjection-site 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 Cimzia (certolizumab pegol).

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