Client:

Client

Submitted By:

Submit by

Begin Date:

Date

Medication Informed Consent

It is your legal right to determine the extent of any treatment or procedure. Please read this form and have your questions answered to your satisfaction before signing.

Medication Start Date:

medConsentSignStartDate

Medication Name:

medConsentSignMedicationName

Medication Description and Purpose:

medConsentSignDescriptionPurpose

Dosage/Frequency:

medConsentSignDosageFrequency

Psychiatric Diagnosis:

medConsentSignPsychDiagnosis

Expected Benefits

medConsentSignBenefits

Potential Side Effects May Include:

medConsentSignDiscomforts

Tell your doctor and seek medical help immediately if you experience any serious side effects.

Potential Risks:

medConsentSignRisks

Alternative Procedures (benefits, discomforts, and risks):

medConsentSignAlternatives

I have been given a chance to ask all the questions I want and have had them answered. I understand that I can change my mind, take away my consent, and stop the procedure at any time. I also understand that if I do not give my consent or, if I choose to take my consent away, it will not cause a problem in the future regarding services and supports I receive.

The effectiveness of the procedures will be reviewed by your psychiatrist and HRC at least annually. Your psychiatrist will also screen for extrapyramidal symptoms.