Forms – Medication Consent – Benzodiazepine

Medication Consent – Benzodiazepine

medication consent benzodiazepine 2020-11-13

Benzodiazepine Medication Consent
Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Is the patient 18 or older?*
- Yes
- No
Drug name*
Your psychiatrist/psychiatric nurse practitioner would like to begin/continue this medication to help you with the following problems:*
- Anxiety
- Other
Other problem*
All medications have side effects and vary from person to person. Some of the possible side effects include:
Common:
Clumsiness, unsteadiness
Dizziness, drowsiness or light headedness
Slurred speech, irritability, aggression

Rare:
Confusion, fast or irregular heartbeat, blurred vision
Dryness of mouth

Very rare, but potentially life-threatening:
Abnormal thinking
Seizures, if stopped abruptly – shaking, bruising, and increase in anxiety

If you experience any of these side effects or any other unusual feelings, please call the office at (860) 437-4550. If the concern is severe enough, please proceed to the closest emergency room.

*Please be advised that discontinuing some of these medications abruptly can result into problematic side effects or recurrence of original symptoms.

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*
- We were provided a copy of this consent form.
Parent/Guardian Signature*
Patient Signature*
Email*
Today's date*
MM slash DD slash YYYY
Please click SUBMIT when complete

Forms – Medication Consent – Benzodiazepine

Medication Consent – Benzodiazepine

Benzodiazepine Medication Consent

Please click SUBMIT when complete