CutisCo iPLEDGE Consent For Patients Who CANNOT Get Pregnant

To be completed by the patient (and parent or guardian if the patient is under age 18) and signed by the doctor.

Read each item below and initial in the space provided if you understand each item and agree to follow your doctor's instructions. A parent or guardian of a patient under age 18 must also read and understand each item before signing the agreement.

Do not sign this agreement and do not take isotretinoin if there is anything that you do not understand about all the information you have received about using isotretinoin.

Patient's Full Name

Patient Address:

Street Number, Street, City, State, Zip Code

Email

For iPledge registration and login

Telephone:

Format: (000) 000-0000.

Patient's Age

1. I understand that isotretinoin is a medicine used to treat severe nodular acne that cannot be cleared up by any other acne treatments, including antibiotics. In severe nodular acne, many red, swollen, tender lumps form in the skin. If untreated, severe nodular acne can lead to permanent scars.

Initials

2. My doctor has told me about my choices for treating my acne.

Initials

3. I understand that there are serious side effects that may happen while I am taking isotretinoin. These have been explained to me. These side effects include serious birth defects in babies of pregnant patients. [Note: There is a second Patient Enrollment Form for Patients who can get Pregnant]

Initials

4. I understand that some patients, while taking isotretinoin or soon after stopping isotretinoin, have become depressed or developed other serious mental problems. Symptoms of depression include sad, "anxious" or empty mood, irritability, acting on dangerous impulses, anger, loss of pleasure or interest in social or sports activities, sleeping too much or too little, changes in weight or appetite, school or work performance going down, or trouble concentrating. Some patients taking isotretinoin have had thoughts about hurting themselves or putting an end to their own lives (suicidal thoughts). Some people tried to end their own lives. And some people have ended their own lives. There were reports that some of these people did not appear depressed. There have been reports of patients on isotretinoin becoming aggressive or violent. No one knows if isotretinoin caused these behaviors or if they would have happened even if the person did not take isotretinoin. Some people have had other signs of depression while taking isotretinoin (see #7)

Initials

5. Before I start taking isotretinoin, I agree to tell my doctor if I have ever had symptoms of depression (see #7), been psychotic, attempted suicide, had any other mental problems, or take medicine for any of these problems. Being psychotic means having a loss of contact with reality, such as hearing voices or seeing things that are not there.

Initials

6. Before I start taking isotretinoin, I agree to tell my doctor if, to the best of my knowledge, anyone in my family has ever had symptoms of depression, been psychotic, attempted suicide, or had any other serious mental problems.

Initials

7. Once I start taking isotretinoin, I agree to stop using isotretinoin and tell my doctor right away if any of the following signs and symptoms of depression or psychosis happen. I:

Start to feel sad or have crying spells
Lose interest in activities I once enjoyed
Sleep too much or have trouble sleeping
Become more irritable, angry, or aggressive than usual (for example, temper outbursts, thoughts of violence)
Have a change in my appetite or body weight
Have trouble concentrating
Withdraw from my friends or family
Feel like I have no energy
Have feelings of worthlessness or guilt
Start having thoughts about hurting myself or taking my own life (suicidal thoughts)
Start acting on dangerous impulses
Start seeing or hearing things that are not real

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8. I agree to return to see my doctor every month I take isotretinoin to get a new prescription for isotretinoin, to check my progress, and to check for signs of side effects.

Initials

9. Isotretinoin will be prescribed just for me. I will not share isotretinoin with other people because it may cause serious side effects, including birth defects.

Initials

10. I will not give blood while taking isotretinoin or for 1 month after l stop taking isotretinoin. I understand that if someone who is pregnant gets my donated blood, their baby may be exposed to isotretinoin and may be born with serious birth defects.

Initials

11. I have read the Fact Sheet for the iPLEDGE REMS and other materials my provider provided me containing important safety information about isotretinoin. I understand all the information I received.

Initials

12. My doctor and I have decided I should take isotretinoin. I understand that I must be qualified in the iPLEDGE REMS to have my prescription filled each month. I understand that I can stop taking isotretinoin at any time. I agree to tell my doctor if I stop taking isotretinoin.

Initials

I now allow my doctor to begin my treatment with isotretinoin.

Patient Signature:

Date:

Parent/Guardian Signature (if under age 18):

Date:

Informed Consent (For Patients Who Cannot Get Pregnant):