Medication & Medical Service Consent Form

General Agreement

I understand that I have the right to refuse this medication and that it cannot be administered and/or prescribed to me until I have spoken with the prescriber and given consent to it, except in an emergency.My prescriber and I discussed:

What my condition or diagnosis is.
What symptoms the medication(s) should reduce and how likely the medications are to work.
What my chances are of getting better without the medication(s).
What other reasonable treatments are available.
The name, dosage, frequency, route of administration, and duration of prescribed medications.
Side effects of the medications known to commonly occur.
Any special instructions about taking the medications.

Controlled Substance Agreement

. I agree that this practitioner will be the only provider prescribing ADHD medication as seen as the best treatment option per the provider’s recommendation via telemedicine.
I will obtain all of my prescriptions for this medication at one pharmacy. The exception would be an emergency situation or in the unlikely event that I run out of medication. Should such occasions occur, I will inform my provider as soon as possible.
I understand the importance of taking the medication at the dose and frequency prescribed by my provider. I agree not to increase the dose of the medication without first discussing it with my provider. I understand that expected prescription refill dates will be used to promote the optimal use of this medication.
My provider may require random urine testing as a matter of routine monitoring.
I will attend all reasonable appointments, treatments, and consultations as requested by my provider. I will pursue other ADHD consultations/management strategies as necessary.
I understand that I should check with my provider or pharmacist before taking other medications including over-the-counter and herbal products.
I agree to be responsible for the secure storage of my medication at all times. I agree not to give or sell my prescribed medication to any other person. I acknowledge that my provider is not obligated to replace any medication shortfall.
I consent to open communication between my doctor and any other health care professionals involved in my ADHD management, such as pharmacists, other doctors, emergency departments, etc.
I understand that if I break this agreement, my provider reserves the right to stop prescribing stimulant medications for me.
I understand that I must attend my follow-up appointments in order to receive refills.

Please choose ONLY ONE option below:

I have had the opportunity to receive information about my medications from the prescriber, and I consent to this treatment. I understand I can ask questions about my medicines and consent can be withdrawn at any time. (INFORMED CONSENT) I have had the opportunity to discuss information about the medications with the prescriber, and I refuse to consent to the medications recommended. I understand that my prescriber will continue to offer me the chance to take medicine, and information about it, but that I may continue to refuse the medicine. (INFORMED REFUSAL)

Please check the box below:

I understand that the medication(s) the practitioner will prescribe are FDA-approved medications although their use in my condition(s) does not appear as part of their approved labeling.

Patient Full Name:

Patient DOB:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature

Patient's Signature

Date

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Practitioner's Signature

Practitioner's Signature

Date

Your information will be encrypted.