Medication consent

Informed Consent for Treatment with Prolia (denosumab)

Informed consent for treatment with Prolia.

About this form

Prolia (denosumab) is used to treat osteoporosis in postmenopausal women and men at high risk of fracture, glucocorticoid-induced osteoporosis, and bone loss in patients on certain cancer therapies. It works by binding RANKL to inhibit bone resorption.

!Hypocalcemia can occur — calcium and vitamin D supplementation is required.
!Stopping treatment without follow-up therapy can lead to rapid bone loss and an increased risk of vertebral fractures. Do not delay or skip doses.
!Serious skin infections, osteonecrosis of the jaw, and atypical femur fractures have been reported.
!Patients should report dental pain or new thigh / groin pain promptly.

Progress

Benefits

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

Significantly reduces the risk of vertebral, non-vertebral, and hip fractures.Convenient subcutaneous injection every 6 months.

Common side effects

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

Back painPain in arms or legsIncreased cholesterolMuscle pain

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 Prolia (denosumab).

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