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Medication Consent Form Template

The document is a medication consent form that outlines key information about prescribed medications for a patient. It lists the patient's name, date, medications prescribed including dosage and frequency. It also notes that the patient has been informed about the foreseeable risks, side effects and their control, precautions when taking other medications/substances, proper storage, expected benefits, alternatives, complications of prolonged use, and how and when to take the medications. Signatures of the physician, patient, and guardian (if a minor) are required to acknowledge understanding and ability to self-administer or assist in administering the medications.

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prabha
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59 views1 page

Medication Consent Form Template

The document is a medication consent form that outlines key information about prescribed medications for a patient. It lists the patient's name, date, medications prescribed including dosage and frequency. It also notes that the patient has been informed about the foreseeable risks, side effects and their control, precautions when taking other medications/substances, proper storage, expected benefits, alternatives, complications of prolonged use, and how and when to take the medications. Signatures of the physician, patient, and guardian (if a minor) are required to acknowledge understanding and ability to self-administer or assist in administering the medications.

Uploaded by

prabha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

CONVENTIONS PSYCHIATRY & Counseling

4 south 100 rte. 59 unit #6 naperville, il 60563


88 W COUNTRYSIDE PKWY STE. D YORKVILLE IL 60560
Phone: 630/416-8289 FAX: 630/416-8306

MEDICATION CONSENT FORM

Patient: ________________________________________________ Date: __________________________________

Medication Effects /
Prescribed/ Dosage Frequency Side Effects Method of
Administered Explained Administration

I have been informed of prescribed medications, methods of administration, as well as the below noted information:
• The foreseeable risk of using prescribed medication
• The probable side effects, if any, and how they can be controlled
• Precautions regarding the use of other medications, alcohol/illicit drugs with these prescribed medications
• Proper storage of the medications
• The benefits expected from using these medications
• The available alternative, if any, and how they can be controlled
• The complications, if any, related to prolonged use of the medication
• How and why to take the medication
• Who to contact if I have any questions regarding the medications prescribed

I understand that my signature verifies that I am able to self-administer my medication.


(If client is minor, signature by parent or guardian verifies their understanding of the above and ability to assist in administration of
medication)

Signatures:
Physician / Designated Staff: ________________________________________ Date: ____________________________

Patient: ___________________________________________________ Guardian: _____________________________________

90 Day Review Signatures


DATE PHYSICIAN/STAFF PATIENT GUARDIAN

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