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Patient Name:______SSN:______
I have discussed with my physician the fact that he/she is recommending that I take: (circle all that apply):
AbilifyClozarilGeodonPepcidSomnoteZomig
AdderallCogentinHaldolProlixinSonataZyban
Adderall XRConcertaImipraminePropranolStratteraZyprexa
AllergraCylertImitrexProvigilSynthroidZyprexa Zydis
AmbienDepakeneKlonopinProzacTegretolVyvanse
AntabuseDepakote ERLamictalRemeronOther______
AriceptDepakote LeLexaproRemeron SolTabTenex
ArtaneDesyrelLibriumReminylTopamax
AtaraxDexedrineLiCOSRestorilTrazodone
AtivanDexotrosatLuvoxReViaTrileptal
AxertEffexorMelarilRisperdalUltram
BenadrylEffexor XRMetadate CDRitalinValium
BextraElavilMethylinRitalin LAViagra
BusparEskalithNavaneRitalin SRVistaril
CarbatrolExelonNeurontinSarafemWellbutrin
CelebrexFocalinNortripylineScraxWellbutrin SR
CelexaFocalin XRPamelorSeroquelXanax
Chloral HydFluoxetinePaxilSeroquel XRZantac
ClonidineGabitrilPaxil CRSerzoneZoloft
For my treatment, I understand that in the physician’s opinion, this is the most appropriate course of treatment to improve and/or prevent the relapse of my symptoms.
I have discussed and fully understand both the potential benefits and risks of the medications prescribed for me. I understand that a possible risk of the medications prescribed may potentially include long term and /or permanent side effects. I understand that I will be routinely examined to determine if I have developed any negative side effects.
I accept responsibility to keep my physician fully informed of any difficulties that I might be experiencing during these assessments. I understand that side effects from the medication may at times be hidden by these medications and without periodic drug-free trials, may not be observed during my examinations.
I give consent to begin/continue the medication (so described to me). I am fully aware of risks and benefits associated with that treatment and have been given the opportunity to ask any and all questions regarding my care. I understand that at any time I may change my mind and withdraw my consent.
I acknowledge that possibility of cardiac side effects were explained by the doctor and my signature below acknowledges my understanding of this information.
Note: The FDA has recently reported that all antidepressants might be contributory to suicidal ideation.
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Patient/Parent/Guardian Signature Date
As the attending physician, it is my opinion that this patient is capable of giving informed consent. Additionally my designee or I have fully reviewed with the patient the medications described above and am satisfied that the patient understands the issues as discussed.
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Physician Signature Date