Medication Consent Form - Medphych Health Services printable pdf download

Medication Consent Form - Medphych Health Services

MEDICATION CONSENT FORM

Name:

DOB:

Date:

Dr. ________________ has educated me regarding medication that has been prescribed to (please

check one of the following)

me,

my child regarding the benefits and possible side effects of this

medication, possible drug, and/or food interactions that may occur while taking this medication, and the

possible effects of this medication if the person taking this medication becomes pregnant. I have also

been informed of the reason or purpose for which this medication was prescribed.

I also provide consent to my prescriber to have access to my past prescription history.

_________________________________________

____________________________

(Signature of Patient / Parent / Guardian)

(Date)



It is recommended that women who are or may become pregnant, or are breast-feeding, discuss this with their

doctor BEFORE taking any medication.



It is recommended that patients be educated on reporting all side effects they experience, including, but not

limited to, which side effects to report IMMEDIATELY to a health care provider.



It is recommended that any provider prescribing medications to obtain a thorough patient history that should

include (but may not be limited to):

What medication including prescribed over-the-counter medications, the patient is or has been

taking.

What food or drug allergies the patient has

What medical conditions the patient has.



Patient (or guardian) has verbalized understanding of medication education.

Medication Consent Form - Medphych Health Services