OCREVUS Patient Consent Form

Step 1 of 2

To enroll in the OCREVUS Home Infusion Program, you must do the following:
Discuss the program with your Doctor, then read and sign, physically or electronically, the Patient Consent Form (this form). Your Doctor will keep one copy and give you a copy for your files
Your Doctor will complete and submit the Patient Enrollment Form

Your Doctor will send a valid prescription to View Health, who will obtain your medicine from the Pharmacy and bring it to your home for administration at an agreed time

Prescribing Doctor's Details:

Name: *

Clinic:

Patient's Details:

Initials:

Date of Birth:

Please read this entire form carefully before signing it. You may choose not to sign the consent form; however, if you do not give your consent you will not be eligible to receive OCREVUS via the OCREVUS Home Infusion Program.

Patient's Declaration

In order to receive OCREVUS via the OCREVUS Home Infusion Program:

I give permission for my Doctor and any healthcare professional to advise the OCREVUS Home Infusion Program Coordinator (View Health) of information about me and my condition in order for me to be enrolled in the OCREVUS Home Infusion Program
I give permission for the OCREVUS Home Infusion Program Coordinator (View Health) to have access to my personal details and to contact me to ensure that I receive OCREVUS in a timely manner at my home
I accept that Roche Products Pty Limited or other third parties involved in the OCREVUS Home Infusion Program will not make any attempt to determine my identity from the information supplied nor pass any identified information to other persons
I understand that this information will ensure that while I am enrolled in the OCREVUS Home Infusion Program, I will receive my treatment at the correct time and that my identifiable information (such as my full name) will only be shared with personnel responsible for delivering the program (including, but not limited to, the OCREVUS Home Infusion Program Coordinator, Infusion Nurse, Pharmacist, and Episoft Pty Ltd, who will be responsible for managing my health record)
I understand that this service is facilitated by Roche Products Pty Limited for a limited period of time, until 11 June 2024, and that I will not be eligible for home infusions after this date
I understand that a patient registry of de-identified patient and medical information will be maintained by the OCREVUS Home Infusion Program (View Health) for reporting and auditing purposes
I understand the potential for allergic reactions associated with OCREVUS, and that my OCREVUS Home Infusion Program Nurse (View Health) has been trained and equipped to provide treatment to manage a reaction, if necessary. I understand that my Doctor can answer any questions that I might have with regard to allergic reactions associated with OCREVUS, or the treatment of those reactions by my OCREVUS Home Infusion Program Nurse (View Health)
I consent to the OCREVUS Home Infusion Program (View Health) providing de-identified reports of any side effects I may experience with OCREVUS including my initials, details of my Doctor, and treatment details, and to Roche Products Pty Limited collecting, storing and disclosing this information in a de-identified manner to health authorities if required
I consent to the OCREVUS Home Infusion Program (View Health) or Roche Products Pty Limited contacting me and my Doctor to obtain further clinical information about a side effect if required
I understand that while View Health has a detailed infection control procedure that will minimise the risk of my becoming infected with COVID-19, it is impossible to completely eliminate that risk

Patient's name (in full): *

Patient's Signature:

Clear Signature

Date:

For further information, please contact View Health on 1300 466 324. Roche Products Pty Limited, ABN 70 000 132 865, Level 8, 30–34 Hickson Road, Sydney NSW 2000. Medical Information: www.medinfo.roche.com/australia or 1800 233 950. ®Registered Trademark EMVOCR0500 M-AU-00000715 PreparedJun22