Clone of Telehealth Consent Form

INTEGRAL HEALTH ASSOCIATES

I hereby consent to be treated with one or more medications in the following medication class(es), each of which I have indicated below by name and with a check. I understand that this/these medication(s) can be associated with risks, including but not limited to the following possible side effects/risks listed by medication class.

Medication(s):

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Antidepressants: Gastrointestinal discomfort, weight gain or loss, sedation orinsomnia, tremor, restlessness, muscle contractions, sexual side effects, seizures (especially with bupropion), dry mouth, constipation, urinary retention, serotonin syndrome (fever, muscle rigidity that could progress to a life-threatening condition), suicidal ideationMood Stabilizers: Birth defects if taken during pregnancy, cognitive impairment, movement issues, weight gain or loss, rash (especially with lamotrigine)Lithium: Kidney issues including possible kidney failure, thyroid issues, tremor, toxicity if dehydrated or taken with common over-the-counter anti-inflammatory medications such as ibuprofen (Motrin) and naproxen (Naprosyn, Aleve), seizures/muscle spasms/death with high toxicity, cardiac birth defects if taken during pregnancySedatives/Hypnotics: Sedation (including impaired ability to drive or operate machinery), dependence, increased risk of dementia, falls with potential injury, sleepwalkingStimulants: Cardiovascular issues, dependence, anxiety, irritabilityNeuroleptics: Sedation (including impaired ability to drive or operate machinery), weight gain, diabetes, elevation in cholesterol, movement disorders including restlessness, tremor, dystonia (involuntary musclecontraction), muscle rigidity, tardive dyskinesia (which can be permanent), seizures, neuroleptic malignant syndrome (fever, muscle rigidity that could progress to a life-threatening condition), agranulocytosis (clozapine), myocarditis (clozapine)Other Side Effect(s):

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Pregnancy. I understand that there are additional risks in pregnancy, some of which may not be known or characterized due to the ethical limitations in testing pregnant women or other reasons.

My clinician has explained the rationale for the above medication(s) and/or medication classes. We have discussed the risks, and I have had the opportunity to ask questions, which have been addressed to my satisfaction.

I agree to take the medication(s) only as prescribed, and to not makes changes unless discussed with my prescribing clinician.

Name of patient*

First NameLast Name

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Date

Name of legal guardian if patient is under 18 years old

First NameLast Name

Signature of patient (Click on signature line):

Signature*

Signature of legal guardian if patient is under 18 years old (Click on signature line):

Signature

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Medication Consent Form