Informed Consent for Medication

 Date:

Patient name:_____________________________________________

Medication (name, dosage, amount, no. of refills, directions):

¨ Discussed benefits, risks, alternatives and their risks, of medication

¨ Discussed important side effects and what to do in event of occurrence

¨ Discussed potential drug interactions

¨ Discussed necessary related tests (blood levels, etc.)

¨ Patient gave consent after discussion and his/her questions answered

¨ Written educational information dispensed to patient

¨ Other__________________________________________________

Date:

Patient name:_____________________________________________

Medication (name, dosage, amount, no. of refills, directions):

¨ Discussed benefits, risks, alternatives and their risks, of medication

¨ Discussed important side effects and what to do in event of occurrence

¨ Discussed potential drug interactions

¨ Discussed necessary related tests (blood levels, etc.)

¨ Patient gave consent after discussion and his/her questions answered

¨ Written educational information dispensed to patient

¨ Other__________________________________________________

Date:

Patient name:_____________________________________________

Medication (name, dosage, amount, no. of refills, directions):

¨ Discussed benefits, risks, alternatives and their risks, of medication

¨ Discussed important side effects and what to do in event of occurrence

¨ Discussed potential drug interactions

¨ Discussed necessary related tests (blood levels, etc.)

¨ Patient gave consent after discussion and his/her questions answered

¨ Written educational information dispensed to patient

¨ Other__________________________________________________

Figure 5