Home » Patient Agreement Patient Agreement First Name Last Name Email Date of Birth Note: Please read each item below and select box provided to show that you understand each item. *These must also be completed by the parent or guardian of a minor patient (under age 18). Do not sign this consent and do not take SORIATANE (aka Neotigason; generic name, Acitretin) if there is anything that you do not understand. 1) I am female and of childbearing age (12 to 55 years of age) – Select one * Yes - Proceed to the next statementNo - Skip to statement 5 2) I understand Soriatane (Acitretin) may cause serious birth defects and that I should not take this medication if I am pregnant or breastfeeding. I understandI do not Understand 3) I have discussed with my prescriber that if I am sexually active, I will use two forms of appropriate & effective contraception (eg. oral contraceptive pill and condoms), at the same time, for at least one month before taking Soriatane (Acitretin), while I am taking Soriatane (Acitretin) and for three years after stopping treatment. I am not sexually activeI am sexually active and will use 2 forms of contraceptionI am sexually active and will NOT use 2 forms of contraception 4) I understand that I must inform my doctor immediately and stop taking Soriatane (Acitretin) if I become pregnant, or believe I might be pregnant.I understandI do not Understand 5) I understand that I should not donate blood during Soriatane (Acitretin) treatment, and for at least three years after treatment. I understandI do not Understand 6) I have discussed with my prescriber the importance of adhering to my appointments for regularly-scheduled blood tests, associated with Soriatane (Acitretin) treatment. I understandI do not Understand 23+13=?
