Patient Agreement

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