Anticoagulation Therapy Consent Form
Bottumzup Health and Wellness, LLC
You have been prescribed an anticoagulant medication such as warfarin (Coumadin) or apixaban (Eliquis). These medications help prevent dangerous blood clots, but they must be used carefully and monitored closely.
Purpose of This Consent
This form is to ensure you understand:
Why anticoagulants are being prescribed
The potential risks and side effects
Your role in safely using this medication
Medication Information
You are being treated with:
☑ Warfarin (Coumadin)
☑ Apixaban (Eliquis)
☑ Other: __________________________
Anticoagulants help reduce the risk of blood clots but increase the risk of bleeding.
Potential Risks and Side Effects
Easy bruising or bleeding
Bleeding gums or nosebleeds
Blood in urine or stool
Prolonged bleeding from cuts
Serious bleeding (rare but possible)
Seek immediate medical attention for:
Severe headache, dizziness, or confusion
Coughing or vomiting blood
Unusual pain or swelling
Monitoring and Safety Requirements
You must follow dosing instructions exactly
Do not start or stop medications without notifying your provider
Inform all healthcare providers (including dentists) that you are on anticoagulants
Keep scheduled blood tests (such as INR for Coumadin)
Notify us of any falls, injuries, or planned surgeries