Home Urine Pregnancy Test Result and Attestation

Patient Certification of Home Urine Pregnancy Test and iPLEDGE Compliance
By signing below, I certify that the result of my home urine pregnancy test is NEGATIVE and accurately reflects my pregnancy status as of the date signed. I further certify that I have reviewed, understand, and am in full compliance with the iPLEDGE REMS program requirements. I acknowledge that falsifying the result of my home pregnancy test is a serious violation and may result in immediate disqualification from further isotretinoin treatment and removal from the iPLEDGE REMS program. I understand that taking isotretinoin during pregnancy can cause severe birth defects. Should a pregnancy or birth defect occur as a result of taking isotretinoin, I release my healthcare provider from any and all liability related to such outcome.
Take a Photo of the Home Urine Pregnancy Test Result
Date of Test:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Time of Test:

Hour Minutes

AM/PM Option
Patient Signature:
Patient Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Parent or Legal Guardian Signature (if patient is under 18)
I certify that I am the parent or court-appointed legal guardian of the minor named above and have the authority to provide consent on their behalf.
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name (First, Last):

First NameLast Name
Relationship to Patient:
Should be Empty: