Medication consent

Informed Consent for Treatment with Reclast / Zoledronic Acid

Informed consent for treatment with Reclast / Zoledronic Acid.

About this form

Reclast (zoledronic acid) is an intravenous bisphosphonate used to treat and prevent osteoporosis, Paget's disease of bone, and certain cancer-related bone conditions. It strengthens bone and reduces fracture risk.

!Acute-phase reactions (flu-like symptoms) commonly occur within 3 days after the first infusion.
!Risk of low calcium levels — calcium and vitamin D supplementation is required.
!Kidney function monitoring is required; not used in patients with poor kidney function.
!Rare risks: osteonecrosis of the jaw, atypical femur fracture, severe musculoskeletal pain.

Progress

Benefits

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

Reduces vertebral, hip, and non-vertebral fracture risk in osteoporosis.Once-yearly infusion improves adherence.

Common side effects

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

Flu-like symptoms (fever, body aches)HeadacheNauseaJoint 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 Reclast (zoledronic acid).

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