Forms – Medication Consent – Lithium

Medication Consent – Lithium

medication consent Lithium 2020-11-13

Lithium Medication Consent
Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Is the patient 18 or older?*
- Yes
- No
Your psychiatrist/psychiatric nurse practitioner would like to begin/continue this medication to help you with the following problems:*
- Mood stabilization
- Other
Other problem*
All medications have side effects and vary from person to person. Some of the possible side effects include:
Common:
Frequency of urination and increased thirst
Tremors
Salty or metallic taste
Weight gain
Nausea and diarrhea
Can cause lower sodium
Dizziness

Rare:
Confusion and slow thinking, skin rashes, acne
Decrease in thyroid functioning – dry puffed skin, weight gain, muscle aches

Very rare, but potentially life-threatening:
Kidney damage
Heart irregularity

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 – Lithium

Medication Consent – Lithium

Lithium Medication Consent

Please click SUBMIT when complete