CONSENT for TREATMENT with Benlysta (Belimumab)

Header

CONSENT FOR TREATMENT WITH Benlysta (belimumab)

I, ______, voluntarily consent to the administration of Benlysta for the purpose of ______.

I acknowledge receipt of one or more information sheets, which further describe Benlysta (belimumab) including the method of delivery, patient instruction and important safety information including the possible side effects and risks of this medication.

In addition, I understand that my care requires the use of an intravenous catheter. I have been informed and am aware of certain risks associated with this procedure.

I certify that I have read and understand this consent form and agree to receive Benlysta (belimumab) intravenous treatment. I have had an opportunity to discuss this treatment with my physician and ask questions regarding this treatment. I have received a signed copy of this form for my record.

______WITNESS Signature of patient or Authorized representative

Date______Relationship to patient if signer not patient

I hereby certify the risks and benefits of, as well as the alternatives to, the above stated treatment including risk and benefits of any alternative treatments, ant the possible consequences if no treatment is undertaken.

Footer