Pharmacist Prescribed Naloxone Informed Consent Form

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Pharmacist Prescribed Naloxone Rescue Kit – Informed Consent Form
Name_________________________________ Birthdate______________ Chart Number____________
Address_______________________________ Phone (_____)__________ PCP ___________________
Before giving your consent, be sure you understand both the pros and cons of the naloxone rescue kit. If you
have any questions, we will be happy to discuss them with you. Do not sign your initials at each section or your
name at the end of this form until you have read and understood each section. Do not sign until the pharmacist
has answered your questions and can witness your signature. This information is confidential.
Contents:
The naloxone rescue kit I will receive contains:
Needle-free syringes of naloxone rescue medication
Nasal adaptors
Patient handout with instructions how to administer naloxone
Written material containing information on overdose prevention, recognizing overdose, responding, and aftercare
information including information on obtaining refills
Overdose Antidote:
_____ I understand that I will be given naloxone because I am at risk to stop breathing and of death due to an opioid
overdose.
_____ I understand and can recognize the signs and symptoms of an overdose.
_____ I understand that naloxone is a drug that reverses an opioid overdose.
_____ I understand that naloxone can reverse an overdose, but does not treat abuse or addiction.
_____ I understand how to use and administer the naloxone to both myself and to someone else.
_____ I understand naloxone may cause withdrawal symptoms, including nausea, vomiting, sweating, fast heart rate,
increased blood pressure, & shakiness.
_____ I understand that naloxone may cause withdrawal symptoms within minutes after administration, which can last
for an hour or more.
_____ I understand that most opioids remain in the body longer than naloxone, and that I could overdose again after the
naloxone wears off.
_____ I understand that naloxone will reverse an overdose from opioids including morphine, codeine, fentanyl,
oxycodone, hydrocodone, OxyContin®, Percocet®, Vicodin®, other prescription pain medications, heroin and
methadone.
_____ I have been shown/understand how to put the naloxone together to use in case of emergency.
_____ I understand naloxone does not prevent deaths caused by other drugs such as benzodiazepines, cocaine,
methamphetamines or alcohol.
Additional Information:
_____ I understand I must return to the pharmacy to request a refill or to replace an expired medication.
_____ I have been counseled on how to avoid an overdose and what to do if an overdose occurs.
_____ I understand my pharmacist is available to provide information on substance abuse/treatment & that I can ask
questions at any time.
_____ I understand when to call 911 & the Poison Center (1-800-222-1222), which is free & anonymous.
The pharmacy can be contacted at _________________.
Sharing Information:
_____ I understand it is strongly encouraged to share this treatment information with my family & friends.
_____ I understand it is strongly encouraged to teach family & friends how to respond to an overdose.
_____ I understand that my provider will be notified that I am obtaining naloxone.
I understand that my signature below indicates that I have received a copy of the Notice of Privacy Practices, addressed any
questions/concerns and have read and understood the information on starting the naloxone therapy.
__________________________________ ___________________________________ ______________
Printed Name
Signature
Date
Date Written: ______ Drug/Sig/Quantity: ________________________________ Pharmacist: _______________

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