Informed Consent for Treatment with Rituximab (Rituxan / Truxima / Ruxience)

About this form

Rituximab is a monoclonal antibody used to treat rheumatoid arthritis, certain forms of vasculitis (granulomatosis with polyangiitis, microscopic polyangiitis), and other autoimmune and hematologic conditions. It targets and depletes B-cells.

!Severe and sometimes fatal infusion reactions; premedication is given.
!Reactivation of hepatitis B can occur — screening is required.
!Increased risk of infections, including serious viral and bacterial infections.
!Rare cases of progressive multifocal leukoencephalopathy (PML).
!Tumor lysis syndrome and severe mucocutaneous reactions reported in cancer settings.

Progress

Patient information

Patient name *Date of birth *

Benefits

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

Effective for refractory RA, ANCA-associated vasculitis, and several autoimmune conditions.Treatment effect can last 6+ months between courses.

Common side effects

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

Infusion reactionsBody aches and fatigueIncreased infection riskLow blood counts

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 Rituximab.

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