Alpha-Agonist Medication Consent

Patient Name*

First Last

Patient Date of Birth*

Is the patient 18 or older?*

Medication Name*

Other medication, please specify*

Your psychiatrist/psychiatric nurse practitioner would like to begin/continue this medication to help you with the following problems:*

Attention deficit hyperactivity disorder (ADHD) e.g. Inattention; hyperactivity; impulsive behavior
PTSD
Other

Other problem*

All medications have side effects and vary from person to person. Some of the possible side effects include:

Off label Acknowledgement*

I have been made aware that prescriptions for children and adolescents may be “off-label,” meaning that pharmaceutical companies have not sought FDA approval to market medications for the treatment of youths.

Treatment Acknowledgment*

I understand that treatment will be monitored by me as well as the provider and that I will have access to the provider if I have questions or my child has problems with the medication

Side Effect Acknowledgement*

The provider has reviewed the above possible side effects with us and we understand that we have the right to refuse or discontinue medications, but agree to discuss this with our provider first.

Consent Form Acknowledgement*

Parent/Guardian Signature*

Patient Signature*

Email*

Today's date*

Forms – Medication Consent – Alpha-Agonist