Aclasta Infusion Consent Form

HFGP Consent Form to Receive

Zoledronic Acid (Aclasta®) Infusion Consent Form

Patient Details

First name *

Surname *

Date of Birth *

Select GP *

Zoledronic acid (Aclasta®) is a medication used to strengthen bones and reduce the risk of fractures in conditions such as osteoporosis.

It is given as an intravenous (IV) infusion, usually once every 12 months.

Please read the following information carefully and tick each box to confirm your understanding.

Be careful driving or operating machinery until you know how Aclasta affects you.

If you are travelling home by car after the infusion, please wait for 15 minutes before you do, or arrange to have someone drive you.

Treatment Information

I understand that Aclasta® (zoledronic acid) is being recommended to help treat osteoporosis or another bone condition.

*

I understand that treatment may help reduce the risk of fractures and improve bone strength. *

Risks and Side Effects

I understand that I should be well hydrated before the infusion unless otherwise advised by my doctor. *

I understand that blood tests may be required before treatment, including kidney function and calcium levels.

*

I understand that I should maintain adequate calcium and vitamin D intake before and after treatment unless otherwise advised.

*

I have informed my doctor if I:

Have kidney disease
Have low calcium levels
Am pregnant or breastfeeding
Have dental problems or require major dental work
Have had previous reactions to bisphosphonate medications

*

I understand that common side effects may include:

Flu-like symptoms such as fever, muscle aches, joint pain, headache or fatigue, especially after the first infusion
Nausea or dizziness
Mild discomfort at the infusion site

*

I understand that less common but more serious risks may include:

Low calcium levels
Kidney impairment
Osteonecrosis of the jaw (jaw bone problems)
Unusual thigh bone fractures
Severe allergic reactions

*

I have had the opportunity to discuss and clarify any concerns with my doctor *

I have been informed about the out of pocket charges for the infusion is $150 (plus any associated consultation) and that $150 is not refundable from Medicare.I understand that I may need more than one infusion. *

I understand that in the event of an emergency during the procedure, I will be treated, and if needed an ambulance called, and sent to hospital. I understand that this may incur extra cost. *

By submitting this form electronically, I acknowledge that this electronic consent is equivalent to my handwritten signature.

Signature *

Draw signature|Type signatureClear

Date *