I am a patient at Thomas Park, M.D. & Associates. Before I sign this form, I talked to my doctor. I understand:

• The kind of condition I have.
• The reason why my medication is given to patients with my condition.
• The way the medication may benefit me.
• The most important kinds of problems (risks and discomforts) that the medication can reasonably be expected to cause patients with my condition.
• Other kinds of choices (alternatives for care) if I do not take the medication(s).
• My prescriber has explained to me that there may be other risks if I take the medication. They are believed to be small, are not expected, or are unknown.
• I understand that because it can be dangerous to stop taking a medication too quickly, I may have to continue taking a medication for a given time even after I decide to have it stopped.
• No one has given me a promise or guarantee to what will happen if I take the medication.
• All of my questions about the medication have been answered. I know that I can ask my doctor questions which I think of late, and my doctor will answer them.
• After thinking about all these things, I have decided that I want to take the medication listed at the top of this form.
• I give my consent to receive the medication at the top of this form.
• I also give my consent to my prescriber to change the amount, times, combination, and ways the medication is given as they think best.
• I know that if I agree to receive the medication, and later change my mind, I must tell my doctor.
• I understand that I may withdraw this consent at any time, verbally or written.
• I know that I should tell my doctor immediately if there are any changes in my condition after I begin taking the medication.