Informed Consent for Psychotropic Medications

Please fill out the following form.

Patient's Name

Birthday

Día

Mes

Año

I understand if I become suicidal, I need to call or 800-273-8255

I understand that all medications have some chance of dangerous side effects.

I understand that not fully disclosing which current medication(s) I am taking could lead to life threatening complications.

I understand that I must notify the office of any changes in medications or medical conditions.

I am currently taking the following medication(s):

I currently have the following medical conditions:

I understand that I should not take these medication(s) while pregnant and if I discover I am pregnant, I should inform Dr. Ancona immediately.

I was given information about the medications, its side effects and the risk//benefits including not taking alcohol and/or drugs while taking these medications:

Medication instructions:

Signature

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Dr. Ancona has explained these reasons for taking the above medication(s), including the risks and benefits of treatment, the likelihood of improving without of improving without medications, and the possible alternative treatments. The most common side effects associated with the medication(s) have been explained, and I understand that other possible side effects from the medication may occur. If any untoward side effect should occur, I have been instructed to promptly notify my physician or a clinical member. I understand that by giving this consent. I am giving permission for use of medication for treatment of my mental disorder. I also understand that there may be risks associated with my treatment as well as benefits for discontinuation of the prescribed medication(s) without consulting my physician may result in worsening of my condition.

Client Signature: _______________________ Date:______________

Parent/Guardian

Signature: _______________________ Date:______________

Dr. Ancona’s

Signature: _______________________ Date:______________