Information for Healthcare Professionals
The following forms and checklists are for use by physicians as part of the Patient Engagement and Education Resource (PEER™) Program:
Patient Information/Consent/Agreement Form: This form should be signed by all patients and physicians
prior to starting Epuris®. It is designed to ensure that patients have been counselled on and understand all risks, including
the psychiatric and teratogenic risks, associated with isotretinoin prior to starting treatment. Give one copy of the form to your patient and keep the second copy in your medical file.
Pregnancy Prevention Checklist:This checklist includes criteria which MUST
be met prior to prescribing this drug to female patients of childbearing potential.
Monthly Pregnancy Reminder Slips: Monthly pregnancy reminders for you to use at each patient visit.
Epuris® Treatment and Patient Monitoring Checklist: A checklist for youto use at each patient visit.
Laboratory Monitoring Guide: Details the laboratory tests that should be carried out.
Mental Health Questionnaire: To assist physicians in screening/ monitoring patients before and during treatment.
When prescribing this drug to female patients of childbearing potential, physicians MUST use the Epuris® PEER™ Program.
Hard copies of these materials are also available by contacting
Cipher Pharmaceuticals Inc.
