Sublocade Informed Consent

I, First Name Last Name understand that the Medical Staff has recommended a medication known as Sublocade to help me stop consuming Opioids. I understand the Sublocade is a prescription medicine used to treat adults with moderate to severe Opiate Use Disorder who have received treatment with an oral transmucosal buprenorphine containing medicine for at least 7 days. Sublocade is part of a comprehensive treatment plan that includes counseling.

I agree to keep appointments and let appropriate staff know if I will be unable to show up as scheduled.I agree to report my history and symptoms honestly to my physician, nurse, and counselors. I also agree to inform staff of all other physicians and dentists whom I am seeing; of all prescription and non-prescription drugs I am taking; of any alcohol or street drugs I have been using; and whether I have become pregnant or have developed hepatitis.I understand that Sublocade is a controlled substance because it contains buprenorphine.I understand the serious risk of potential harm or death from self-injecting Sublocade intravenously.

While Sublocade has been studied in clinical trials to be safe and effective, you may experience side effects. These may include:

Injection Site reactions (pain, tenderness, redness, itching, swelling, infection, tissue damage)
Liver Problems (increase in liver enzymes)
Allergic reaction (hives, swelling, wheezing, dizziness)
Decrease in Blood Pressure
Constipation, headache, nausea, vomiting, tiredness

I understand that long term chronic use of opiates including SUBLOCADE may cause fertility problems in males and females.I have reviewed the potential side effects and adverse reactions, and I understand the risks inherent in this treatment. I have received a MEDICATION GUIDE for SUBLOCADE. I have had my questions answered adequately, and I do provide my informed consent to receive this medication

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SUBLOCADE INFORMED CONSENT