Medication Effect and Side Effect Agreement

Regarding the Assigning of Prescription Drugs

The purpose of this form is to facilitate the highest level of mutual confidence and awareness between the patient and practitioner* by fully explaining each drug prescribed in layman’s terms in regard to it’s effects/possible effects on the patient.

The explanation of the potential effects/side effects is to be broken down not just into common language, but the percentages/possibility of the effects will be given in the most accurate terms or numbers possible. If no percentage/possibility is currently available, the practitioner will make that aware to the patient also.

After reading this form, and then abiding by the terms, the practitioner must fill out and sign this agreement. Once signed, both the patient and doctor will be bound by the terms of this consent form for each drug given to the patient.

If any practitioner refuses to be bound by the terms of the agreement, it is highly suggested that the patient consider whether or not to continue treatment with the aforementioned practitioner. Any practitioner who intentionally falsifies, intentionally misrepresents, or intentionally withholds information that may cause damage or grievous injury to the patient may find themselves subject to the full penalty of the law for perjury or malpractice.

Name of medication to be prescribed: (Use reverse for adverse side effects disclosure)

________________________________________________________

Name of Practitioner prescribing medication to be legibly printed below: ________________________________________________________

Signature of Practitioner: _______________________________________ Date: ____________

Name of patient to be legibly printed below:

_________________________________________________________

Signature of patient:

_______________________________________ Date: ___________

* The term “practitioner” is to represent the doctor, nurse, anaesthesiologist, or other who

may prescribe medicine to the patient. One form for each prescribed medication is necessary.

For your free copy of this form (fax or Word format), please email a

request to mrproactive@earthlink.net Or leave a message at (509) 732-4366.

Adverse Side Effects Descriptions*

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* Adverse side effects descriptions can often fill several pages. If necessary, please

copy this page to attach and write in the appropriate page number below right.

PAGE ______

For your free copy of this form (email or Word Perfect format), please email a

request to mrproactive@earthlink.net,

Or leave a message at (509) 732-4366 and I can send a copy via USPS mail. .

Produced by William C. Brumbaugh   http://www.proactivenews.com