Get Glaze Education

Filling out the Glaze Education online form is an essential step for ensuring proper understanding and compliance with the requirements of the Erivedge treatment. This guide provides clear and detailed instructions to help you navigate each section of the form effectively.

Follow the steps to successfully complete the Glaze Education online form.

1. Press the ‘Get Form’ button to access the Glaze Education online form and open it in the appropriate editor.
2. Begin by reviewing the initial patient acknowledgment section. Ensure you understand the important warnings associated with Erivedge, such as potential embryo-foetal death and severe birth defects.
3. Complete the ‘For All Patients’ section by acknowledging the serious risks of Erivedge. Confirm that you will not share this medication and that it remains out of reach of children.
4. Proceed to the ‘For Women Who Could Become Pregnant’ section. Answer the questions regarding your pregnancy status and understand the required birth control measures to be taken during and after treatment.
5. In the provided fields, indicate your gender, age, and circling whether you are a woman of childbearing potential. Additionally, document the results of your pre-treatment pregnancy test.
6. Fill out your name, sign the patient confirmation statement, and date it. Ensure that your healthcare provider has discussed the risks thoroughly with you.
7. Next, the healthcare provider must complete the confirmation section. They will fill in their name, sign, and date the document, confirming that they have explained the treatment risks.
8. Once all fields are filled out and confirmed, retain the original signed document for your records. Make sure to provide a copy to your healthcare provider.
9. Finally, ensure that your healthcare provider confirms the completion of the form through the pregnancy prevention web portal.

Complete your Glaze Education online form today to ensure your understanding and safety regarding Erivedge treatment.