Isotretinoin "accutane" / IPLEDGE

Isotretinoin "accutane" / IPLEDGE

TELEMEDICINE VISIT
Date

Month Day Year
Date
Name *

First Name Last Name
I am a *

Male Female* (on two form of birth control) Female (post menopausal) Other
Which month of treatment is this? *

Starting isotretinoin Completing 1st month Completing 2nd month Completing 3rd month Completing 4th month Completing 5th month Completing 6th month month after completion to close out Ipledge (women only)
Current dose *

10 20 40 60 80 100 I'm not sure I haven't started yet
Mark any side effects or symptoms you may be experiencing: (even those NOT on the medication should respond to any preexisting symptoms) *

dry lips dry eye hair loss depression bloody stool nose bleeds loose stool, diarrhea or constipation muscle ache pain in tendon (e.g., achilles, tendon above your heel) back ache change in vision trouble seeing at night I AM NOT EXPERIENCEING ANY CHANGES OR PERCEIVED SIDE EFFECTS Other
My acne is: *

unchanged or about the same worse better clear, no new break outs
Upload current photos of your skin here *

You may take photo with your mobile phone or uploaded image from your computer
Cancel of
Urine pregnancy test. Please mark date on handle with a Sharpie and photograph

You may take photo with your mobile phone or uploaded image from your computer
Cancel of
Is the date of the test marked clearly on the handle? This date starts the 7 day window during which time you will need to see the doctor, sign into your Ipledge account, and pick up your medicine. (day 1 being date of pregnancy test) *

Yes No, I will retake the photo and upload with date No, I am having the test done through the lab
Primary Birth Control method:blanks .
Secondary Birth Control method blank .
You must confirm these 2 forms in the above order by entering them into the Ipledge program system after your visit in order to have your prescription released from the pharmacy for a maximum 30 day supply.

Copay or deductible (if you are unsure of your payment, please contact our office or may payment of $80 and we will bill or refund according to your insurance obligation.

USD ipledge visit

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Credit card

Visa Mastercard AMEX Discover Other
Signature

Clear
A video call will be scheduled as soon as all the pertinent information is gathered.

Please note, any lab work needed or reviewed will be discussed during the visit.

If anything is missing, our office will notify you as soon as possible.
My signature verifies my understanding of and compliance with the Ipledge program. I agree not to share the pill; I understand I cannot donate blood; I agree to use 2 forms of birth control throughout my treatment and one month after; I agree to provide necessary blood work/urine pregnancy tests to ensure my safety while taking the medication, report any side effects and make an appointment in a timely manner in order to satisfy prescription windows.

Clear
My signature verifies my understanding of and compliance with the Ipledge program. I agree not to share the pill; I understand I cannot donate blood; I agree to provide necessary blood work to ensure my safety while taking the medication, report any side effects and make an appointment in a timely manner in order to satisfy prescription windows.

Clear
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