High Risk Drugs Consent Form
This form is designed to obtain consent from patients receiving high-risk drugs, ensuring they understand and agree to the terms of care and safety procedures.
Patient Name
*
First Name
Last Name
Start of Care Date
*
-
Month
-
Day
Year
Date
Diagnosis
*
Facility Name / Care Home
*
First Name
Last Name
Authorization Statements
I authorize the pharmacy nurses to provide medication and related services.
I understand that I am responsible for complying with all prescribed instructions.
I acknowledge that I have received and understood the teachings provided.
I accept responsibility for my safety during medication administration.
I consent to family notification regarding my treatment.
I agree to drug monitoring procedures as part of my care.
I am aware of emergency procedures and know how to contact emergency services if needed.
Legal Responsibility Party Signature
*
First Name
Last Name
Title of Responsible Party
Nurse Signature to Confirm Consent and Acknowledgment
*
First Name
Last Name
Submission by Authorized Representative
*
Patient
On Behalf of the Patient
Patient signature
*
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Should be Empty: