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Salveo Integrative Health
Home
About
About Us
FAQ’s
Featured Spotlights
The COVID Vaccine (Dr. Naveed)
TMS Therapy (Sahara Khan)
Georgia
Our Staff
Services
Ketamine IV Infusion Treatment
TMS Therapy
TMS at Salveo
Telemed
Pharmacy
For Organizations
Staffing/Jobs
North Carolina
Telemedicine
For Organizations
Make a Payment
Appointments
Salveo Foundation
Blog
Contact
Careers
Blog
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Name:
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Date of Birth:
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SHAHZAD M. HASHMI, MD OR
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Has Explained that the best treatment for my problem would include the use of the following medication.
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Medication:
Dosage Range:
I have been given a copy of the:
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Patient Information Sheet
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.
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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:
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I am Pregnant
I am not Pregnant
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Other Physical disorders
type any Physical Disorders
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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
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