Consent Form for Injection by a Nurse

This is a Consent Form for receiving an injection by a Nurse employed by ExtraCare as part of the support program intended for patients treated with the ILUMYA 100MG/ML preparation.

I, the undersigned

Patient’s Name

First

Last

Id. No.

Phone

Hereby certify:

The receipt, by means of a Nurse employed by ExtraCare, of a treatment/injection of the ILUMYA 100MG/ML medication, which has been prescribed to me by the Attending Physician, and I confirm that I have read the medication’s consumer brochure and received an explanation from my Attending Physician regarding the medication, and that I have in my possession a valid injection instruction provided by my Attending Physician, for receiving an injection in a home setting.

** I am aware that there exists an option of carrying out the injection as part of the services of the HMO, nonetheless, I am interested in receiving the injection at my home by means of a Nurse employed by ExtraCare.

Patient’s Signature

?Are you over 18 years of age and qualified to sign the consent form

Yes
No

Patient’s Name

First

Last

Date

In the case of a minor or a patient who is not legally competent to sign this consent:

A copy of a Power of Attorney or Guardianship Order must be appended, as applicable.

Guardian’s Name

First

Last

Id. No.

Date