Medication consent

Informed Consent for Treatment with Simponi Aria (golimumab)

Informed consent for treatment with Simponi Aria.

About this form

Simponi Aria (golimumab) is a TNF blocker delivered as an intravenous infusion. It is approved for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, and pediatric polyarticular JIA.

!Serious infections including TB, fungal, viral, and bacterial.
!Increased risk of lymphoma and other malignancies.
!Hepatitis B reactivation; screening required.
!Heart failure can worsen.
!Nervous system disorders (rare).

Progress

Benefits

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

Reduces inflammation and slows joint damage in RA, PsA, AS, and JIA.Maintenance dosing every 8 weeks after initial loading.

Common side effects

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

Upper respiratory infectionsElevated liver enzymesViral infectionsBronchitis

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 Simponi Aria (golimumab).

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