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Prolia consent form 2026

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  1. Click ‘Get Form’ to open the Prolia consent form in the editor.
  2. Begin by reviewing the introductory section that explains what Prolia is and its purpose. This will help you understand the treatment you are consenting to.
  3. In the 'Administration' section, note that Prolia is administered via injection every six months. Ensure you acknowledge this by checking any relevant boxes if provided.
  4. Fill out the 'Medical History' section by indicating any conditions or medications that may affect your treatment. This includes low blood calcium levels, kidney issues, or pregnancy status.
  5. Review the side effects listed carefully. If you have questions, consider discussing them with your healthcare provider before signing.
  6. Finally, complete the certification section by signing and dating the form. Ensure all required fields such as patient name and witness signature are filled out accurately.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

The majority of commercial and Medicare plans cover Prolia. The list price for Prolia is $1,875.43 , per injection every six months. Most patients do not pay the list price. Your actual cost will vary.
Informed consent language should be written in the second person (you), not in the first person (I). Minimize passive voice to the extent possible. Example of passive voice: A summary of results will be sent to all study participants. Example of active voice: We will send you a summary of the results.
All requests for Xgeva (denosumab), Prolia (denosumab) require a prior authorization and will be screened for medical necessity and appropriateness using the criteria listed below.
Medicare may cover them, though you may need to request prior authorization.
Prolia is administered as a single injection under the skin (subcutaneous) every 6 months. The injection can be in your upper arm, upper thigh, or abdomen.

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Prolia / Minnesota Department of Human Services

This is the prior authorization (PA) criteria for coverage of this drug under Minnesota Health Care Programs (MHCP).

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