Medication consent

Informed Consent for Treatment with Remicade / Inflectra (infliximab)

Informed consent for treatment with Remicade / Inflectra.

About this form

Infliximab (Remicade or its biosimilars including Inflectra) is a TNF blocker used to treat rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, plaque psoriasis, Crohn's disease, and ulcerative colitis.

!Serious infections including TB, fungal, viral, and bacterial.
!Increased risk of lymphoma and other malignancies.
!Hepatitis B reactivation; screening required prior to therapy.
!Heart failure may worsen.
!Infusion reactions and serum-sickness-like reactions can occur.

Progress

Benefits

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

Highly effective in reducing inflammation and joint damage across multiple inflammatory conditions.Long established efficacy and safety record.

Common side effects

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

HeadacheStomach pain or nauseaUpper respiratory infectionsInfusion 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 Remicade / Inflectra (infliximab).

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