Informed Consent for Treatment with Cimzia (certolizumab pegol)

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

Patient information

Patient name *Date of birth *

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

Any additional questions or notes for our team

Financial responsibility & payment authorization

Biologic and infusion therapies are billed to your insurance, but coverage is not guaranteed until your plan processes the claim. Please read the statements below and sign. This signature is separate from the treatment consent signature.

I understand that my insurance benefits will be verified before treatment begins, and that my plan may require prior authorization. *

Yes — I understand

I understand that I am financially responsible for any deductible, copay, coinsurance, or non-covered charges remaining after my insurance processes the claim. *

Yes — I accept responsibility

I understand that if my insurance denies coverage, our team will contact me before treatment continues, and that I may be responsible for the full cost of the medication. *

Yes — I understand

I authorize Sierra Rheumatology to bill my insurance on my behalf and to receive payment directly for services rendered (assignment of benefits). *

Yes — I authorize

Patient signature — financial responsibility *This is a separate signature from your treatment consent below. Sign with your finger, mouse or trackpad.

Sign here with your finger, mouse or trackpad

Your signature will appear on the exported PDF.

Date signed *

Sign & submit — treatment consent

Patient signature *Sign with your finger, mouse or trackpad in the box below.

Sign here with your finger, mouse or trackpad

Your signature will appear on the exported PDF.

Date signed *Email address (so we can confirm receipt) *

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. Export to PDF works even with partial answers — useful if you want a printed copy to bring in. 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