INFORMED CONSENT FOR MEDICATION

Name:*
Date of Birth:*
Date Format: MM slash DD slash YYYY
SHAHZAD M. HASHMI, MD OR*
Has Explained that the best treatment for my problem would include the use of the following medication.
*
Medication: Dosage Range:
I have been given a copy of the:*
Patient Information Sheet
*
Other written information
I have had the opportunity to discuss the riskd, benefits, and potential side effect of the listed medications with my doctor, and have received a reasonable explanation.

I understand that medications of this type have been successfull in treatment of similar symtoms in others. Further, I understand that there is no guarantee that these agents will be as effective with my particular symptoms. I agree to notify my physician in the even that I experience any side effects or problems with the above medications.
I have informed my doctor that:*
- I am Pregnant
- I am not Pregnant
- N/A
- Other Physical disorders
*
*
I voluntarily consent to take this medication. I also understand that I have the right to withdraw my consent and stop taking medication at any time. If I decide to discontinue the medication, I will tell my doctor immediately, he/she may explain how to safely stop my medication.
Patient/ Parent/ Guardian Signature*
Date:*
Date Format: MM slash DD slash YYYY