es E | IPLEDGE-Committad to Pregnancy Prevention | P LE | Phoenix, AZ 85038 Patient Information/Informed Consent & Brive! st tar ct Eagan dc of (for all patients): poriete dsmged james tal oyeae ies meal pains To be completed by patient (and parent cr guardian it patiert is under age 18) and hia __= b= | signed by the ecto. 7, Once | start taking ince se, | apa a ones ear al ry rte Revd tach ites below and intial in ta apace peovided If you utderstang each term ang TPE wey if any ot the tofiewhing Bens até symptoms of depressian = Ages to follow your doctor's insinuchors, A parent or grandian of & patent under age 18 happen | Ee ai Sacse ast alsa rand ang understand each item tefore vening the agreenest. Sart to fal ot ox Howe eng spale #282 (Oo act sigh this agreemect ard de rot take tsctretinste if trace ts amtving thet you fe interest in acthitien } ance sap ft urdarstant abtut al the itfareatics yru have receoved abast esing isstreticoin. «Looe iterest in acthitvea} ates ¢ LiwJeEFFREN Epstein understand thet listretineis is a medicine used to treat severe nodular acte that «Have a change in mej appaels & bed weights Canet be cleared wp Dy arty cther acne toestreents, citing artinetcs. In severe © Have trouble cercenbatitg s2s-2s2 == fedalar acne, many re¢, sullen, tercer lumps for in the shis, If wteeated. severe + jee nedular acre can ised 02 parmierent scars, © Wither fren ay fnerds a indiats: Fea Hib have a erm see So totosstitse erties 2. My doctor has told me about my choloas tor beating my sone. © Hove fesiogs of worlooanies or OOM t2Secressastwetee™ britiats: © Sart havirg thaaghts aeut herting weyself ec | fy own lite (sebexdel thengtts) “tartar 3. Lunderstand that there ere serious side effects that may happen while | am taking ineretiede, These have bee explained tp ne. Thene side ellis clade seacs © Stat acting on dangetss impaiees ith defects in Bebies of pregnant patieets. Mote There is # second Patiext © Start sewing oF haaring Uengs that a not seal Sgemeateniafomned Cranes Meek Det Outta Gs fanata pte wo con prerne pregna << at te return te see my doctor every mech | take isotretinal te peta new beitiate precrotin for lotrtine to each pres, ante thech fot pa 4 Lenderstand Ghat soere patients, while tabing isxbvtingin o seve ater stopsing site effects, csazrttinan. have became depressed cr cevelages etter serioes mantel prediers. hikes Syrephames of depression inclade sad, “axmtous” or empty mood, inmabilty, acting or —_ pean pee phn Ay ld el 5 babeSnoin will be peor bet gust tor re —! wil net shew isctretiogis with it « in weight or hs own titer people because i re: setinus side effects, nctuding birth dvtects pedarnance guing down, or trouble cancentrabng. Same patierts tabing (satretiogtn a 5 ' hawe Bad thasprts about hurting themselves or gutting ar end t ther own eas otels (untidal theugtts), Sore peaple tried to ent (eis Owe lives. Aed seme pecpie tave ql Grded their own ives, There were regarts iat sere af These people did ect eppear 10. ted mt apetetes Jesemrant baleen thy bn Cepressed. There have beet ceperts ef patinerss cn isstreticeis heceming aggressive ‘ N cr chest, fo ore brows if totretinotn caused these beturvinrs ¢ Cony WUC have ter bathy rey be expaned tx setetiste and suey bo bart OR es, Cee een Pane St oot ate insets Sees pave have hed ster invtiale CeP6 ot Cagenssian wile tating tnretats (ne 11. thane read The PLEDGE Angra Patient kiteductory Brochure ard other naterials Witiels My (roviger gave we cectamng inpartart safety lehermation atcet isrtretingn. 5. afore I start tahing lsctrationtn, | ass bo tell my dactor I Rove ever bad | enderstand ail the infereustion | received, ier uate can wtmintts of th pra alg — ay e any ot these is. 12. My doctor aad | Save created | soul tahe isateetingin. | understand that | mast CE are ant certert soos math ot easag velo wr a qualified in the LECCE program so hawe sy prescriptice fitee each month. | y unéerstané that | can shop tahing isobetinain at ary tna | agree to tall sty decter Waitigls: it stop taking wetretinn « itis; | os tow oy dca mR. Kline 4a Degie my eativect with isoratinsin Pabeet Sputure Aa J+, DOD ParereSGsarden Signature (if utcer age | Oete Oute *) ot Patiast Name (peiet) Cree = Eins Lesa ee Ihave: ’ © tully explained to the patiert, -- De seture ard perpow ot isoternain treatment, inching its benefits ard rshs © given the getient the apprastate educational macenats, The PLEDGE Prograve Pationt Intresuctvy Brucaure and asted the patient # te'sha has any questions regarding hacher testrere wth isstretionen © arseered those questions to the Sest at my abilty Doctor Sipretuse Dare PLACE THE ORIGINAL SIGNED DOCUMENTS ON THE PATIENT'S MEDICAL RECORD. PLEASE PROVIDE A COPY TD THE PATIENT. EFTA00313973