Medication Informed Consent Form - Wraparound Milwaukee
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1Medication Informed Consent
Client: _____________________ DOB: ____/____/_____
I acknowledge receiving an adequate explanation about medications, including:
a. The advantage of taking the medication as prescribed to aid in recovery.
b. The disadvantages and possible side effects associated with the medication.
Having received and understanding the educational information on the class of medication(s)
that have been prescribed, I consent to the use of the medication. I understand that I may
withdraw this consent at any time, but if not withdrawn, consent will remain in effect until the
medication is discontinued by an authorized prescriber.
Medication
Date
Treatment Expectations
______________________
____/____/_______
____________________________________
______________________
____/____/_______
____________________________________
______________________
____/____/_______
____________________________________
______________________
____/____/_______
____________________________________
______________________
____/____/_______
____________________________________
______________________
____/____/_______
____________________________________
_________________ ____/____/_____ _________________ ____/____/_____
Parent/Guardian Signature
Date
Client Signature (If over 14 years)
Date
_________________ ____/____/_____
Witness Signature
Date
_________________ ____/____/_____ _________________ ____/____/_____
Parent/Guardian Signature
Date
Client Signature (If over 14 years)
Date
_________________ ____/____/_____
Witness Signature
Date
_________________ ____/____/_____ _________________ ____/____/_____
Parent/Guardian Signature
Date
Client Signature (If over 14 years)
Date
_________________ ____/____/_____
Witness Signature
Date
_________________ ____/____/_____ _________________ ____/____/_____
Parent/Guardian Signature
Date
Client Signature (If over 14 years)
Date
_________________ ____/____/_____
Witness Signature
Date
“REF” – Indicates client was given medication information but refused to sign – see medical record.
H:\CATC\WRAPCMN\Med Clinic\Medication Informed Consent.docx 2/11/2015
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