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My practitioner has discussed the following for each medication listed below:
  • The diagnosis and target symptoms for the medication(s) recommended (which may or may not be FDA indicated)
  • The possible benefits/intended outcome of treatment, and as applicable, all available procedures involved in the proposed treatment and possible alternatives. The possible results of not taking the medications.
  • The possible risks associated with medication(s), (including any contraindications and increased risks associated with taking medications with pregnancy or as a child/adolescent/young adult).
  • Common or significant adverse effects that are associated with meds. Additional info provided ( ____ printout____ brochure____ verbal___ other (specify)__________________) Meds should not be combined with illicit substances, alcohol, OTC meds, or prescribed meds until discussed with the provider.
  • The possibility that my medication dose may need to be adjusted over time, with regular visits to my practitioner;
  • The possible need for regular laboratory monitoring;
  • My right to actively participate in my treatment by discussing medication concerns or questions with my practitioner; and inform the practitioner of any changes in medication regimen with other doctors;
  • Further, I understand that there is no guarantee that the agent will be effective with my symptoms. I agree to notify my practitioner with any changes or problems with my medications.
  • My right to withdraw voluntary consent for medication at any time
  • The following was also discussed during the consent process
Prescribed Medication(s) for consent on this date:
The information that you provide about you and your family will be used to [describe the purpose of collecting the information e.g. gain an insight into services and what is important to families].
I have read the information above and have had an opportunity to ask questions about the [research / activity] and how my information will be used. I understand the purpose of the [research /activity] and what my participation involves. I agree to take part in [describe what involvement the individual will have e.g. an interview] and for the information I provide to be shared with the [area] Partnership agencies and this in turn allows services that I use to share information about me and my family for the purpose of this [research / activity]. I understand that I need to inform the other members of my family that I have given consent which will allow them to opt out if they wish. I understand that anonymized [information / research] about me and my family may be published within the [project report / relevant document], which may be published online and that published material from this [project / report] may be used and distributed for training and service design and development. I know that my participation is voluntary and that I can choose to withdraw from the research at any point.