Medication consent

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

Informed consent for treatment with Rituximab.

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

I understand my financial responsibility for this treatment. *

Yes — I understand

Any additional questions or notes for our team

Sign & submit

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

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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.

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