Forms – Medication Consent – SNRI

Medication Consent – SNRI

medication consent SNRI 2020-11-17

Antidepressants Medication Consent
Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Is the patient 18 or older?*
- Yes
- No
Medication type*
- Serotonin-Norepinephrine Reuptake Inhibitor
Your psychiatrist/psychiatric nurse practitioner would like to begin/continue this medication to help you with the following problems:*
- Persistent depressed or irritable mood
- Anxiety
All medications have side effects and vary from person to person. Some of the possible side effects include:
Common:
Nausea
Dry mouth
Constipation
Decreased appetite
Fatigue
Increased sweating
Rare:
Mania
Urinary retention

Very rare, but potentially life-threatening:
Serotonin syndrome (high fever, sweating and increased heart rate)
Thoughts or actions of harming themselves

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 – SNRI

Medication Consent – SNRI

Antidepressants Medication Consent

Please click SUBMIT when complete