INFORMED CONSENT FOR MEDICATION Name:* Date of Birth:* 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 SheetI 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.* Other written informationI 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 type any 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:* MM slash DD slash YYYY
