Forms – Medication Consent – Other

Medication Consent – Other

medication consent Other 2020-11-17

Other Medication Consent
Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Is the patient 18 or older?*
- Yes
- No
Specify other medication:
Describe the problems your psychiatrist/psychiatric nurse practitioner would like to begin/continue this medication*
All medications have side effects and vary from person to person. Some of the possible COMMON side effects include:*
All medications have side effects and vary from person to person. Some of the possible RARE side effects include:*
All medications have side effects and vary from person to person. Some of the possible VERY RARE, BUT POTENTIALLY LIFE-THREATENING side effects include:
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 – Other

Medication Consent – Other

Other Medication Consent

Please click SUBMIT when complete