Healthcare iPledge Consent Form

Healthcare iPledge Consent Form

Patient Information

Patient Name:

Date of Birth:   Gender:

Address:

Primary Phone:   Email:

Emergency Contact Name:   Phone:

Insurance Information

Medical History

iPledge Program Consent and Acknowledgment

I, the undersigned patient, acknowledge that I have been informed that the medication associated with the iPledge program carries a significant risk of causing severe birth defects if pregnancy occurs during treatment. I understand and agree to the following requirements and certifications:

1. I understand that I must not become pregnant while taking this medication and for the period after discontinuation as required by the prescribing clinician and program protocol. I acknowledge that I have been counseled about the teratogenic risk and the need for reliable contraception.

2. Contraception: I will use at least one of the following reliable contraceptive methods as instructed. I certify that the contraceptive option(s) I currently use or agree to use are indicated below:

3. Pregnancy Testing: I consent to pregnancy testing prior to initiation of medication and at the intervals required by the iPledge program and my prescriber. I understand that a positive pregnancy test will require immediate cessation of medication and appropriate counseling.

4. Program Participation and Information Release: I authorize my healthcare provider to release and receive information necessary to enroll and maintain my status in the iPledge program, including pregnancy test results, contraception confirmation, and prescription authorizations. I understand that this information will be used only for program compliance, safety monitoring, and clinical care.

5. Risks and Side Effects: I have been informed of the common and serious potential adverse effects, including but not limited to mucocutaneous dryness, mood changes, musculoskeletal symptoms, and the significant risk of fetal malformations. I acknowledge that I had an opportunity to ask questions and that my questions were answered to my satisfaction.

6. Voluntary Consent and Right to Withdraw: My consent to participate in the iPledge program and to receive the medication is voluntary. I may withdraw consent at any time by notifying my prescriber; however, I understand that withdrawal may affect ongoing treatment and program eligibility.

7. Electronic Communications and Recordkeeping: I consent to electronic communication related to program enrollment and monitoring, including reminders and results. I understand that program-related records will be retained in my medical record and program files in accordance with applicable recordkeeping standards.

Acknowledgment and Certification

By signing below I certify that I have read and understand the information on this form, that my responses are accurate to the best of my knowledge, and that I accept the responsibilities required for participation in the iPledge program while receiving treatment. I understand the severe risk of birth defects associated with exposure during pregnancy and agree to comply with the required contraception, testing, and program procedures.

HIPAA Acknowledgment

I acknowledge that I have received or been offered a copy of the healthcare provider's Notice of Privacy Practices describing how my medical information may be used and disclosed. I understand that my protected health information related to the iPledge program will be used and disclosed as necessary for treatment, payment, healthcare operations, and program compliance.

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