Medication consent

Informed Consent for Treatment with Saphnelo (anifrolumab-fnia)

Informed consent for treatment with Saphnelo.

About this form

Saphnelo (anifrolumab-fnia) is approved for moderate-to-severe systemic lupus erythematosus (SLE) in adults receiving standard therapy. It works by blocking the type I interferon receptor.

!Increased risk of serious infections, including upper and lower respiratory infections.
!Avoid live or live-attenuated vaccines during treatment.
!Hypersensitivity / infusion reactions can occur.
!Caution in patients with active or chronic infections.

Progress

Benefits

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

Reduces overall lupus disease activity and may lower steroid burden.First-in-class type I interferon receptor antagonist.

Common side effects

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

Upper respiratory infectionsBronchitisInfusion reactionsHerpes zoster

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 Saphnelo (anifrolumab-fnia).

Submitting transmits this form securely to our office. For urgent medical issues please call our office or 911.

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