Medication Consent – Benzodiazepine medication consent benzodiazepine 2020-11-13 Benzodiazepine Medication ConsentPatient Name* First Last Patient Date of Birth* MM slash DD slash YYYY Is the patient 18 or older?* Yes No Drug name* Your psychiatrist/psychiatric nurse practitioner would like to begin/continue this medication to help you with the following problems:* Anxiety Other Other problem* All medications have side effects and vary from person to person. Some of the possible side effects include: Common: Clumsiness, unsteadiness Dizziness, drowsiness or light headedness Slurred speech, irritability, aggression Rare: Confusion, fast or irregular heartbeat, blurred vision Dryness of mouth Very rare, but potentially life-threatening: Abnormal thinking Seizures, if stopped abruptly – shaking, bruising, and increase in anxiety If you experience any of these side effects or any other unusual feelings, please call the office at (860) 437-4550. If the concern is severe enough, please proceed to the closest emergency room. *Please be advised that discontinuing some of these medications abruptly can result into problematic side effects or recurrence of original symptoms.Off label Acknowledgement* I have been made aware that prescriptions for children and adolescents may be “off-label,” meaning that pharmaceutical companies have not sought FDA approval to market medications for the treatment of youths. Treatment Acknowledgment* I understand that treatment will be monitored by me as well as the provider and that I will have access to the provider if I have questions or my child has problems with the medication Side Effect Acknowledgement* The provider has reviewed the above possible side effects with us and we understand that we have the right to refuse or discontinue medications, but agree to discuss this with our provider first. Consent Form Acknowledgement* We were provided a copy of this consent form. Parent/Guardian Signature* Patient Signature* Email* Today's date* MM slash DD slash YYYY Please click SUBMIT when complete
