Mental Health Evaluations | Child Psychiatrist | Suffolk VA



CONSENT FORM FOR THE USE OF BENZO MEDICATIONSPatient’s Name: ________________________ DOB _______________________________This BENZODIAZEPINE medication__________________________ is being used to manage or control symptoms of ____________________________________.I understand that the use of this medication can cause addiction and carries other risks such as drug interactions, sedation, confusion, poor memory, increased response time and impaired coordination which may increase the risk of motor vehicle accidents and falls. If I am over 65 years of age, I may be especially sensitive to these side-effects. In most situations, benzodiazepines are not recommended for use beyond 4-6 weeks. Given the risks associated with this class of medications, my doctor may reduce or safely stop prescribing benzodiazepines to me at any time during my treatment based on how I respond to treatment and whether continued use could likely harm me.I, (above printed) on INIITAL__________, have been informed and clearly understand that its company policy that I must choose if I want to continue my opioids (i.e., morphine and or morphine like drugs like percocet, vicodin, oxycodone, oxyontin and others or if I want to continue with my benzodiazepines (like valium, xanax, klonopin, diazepam, alprazolam, clonazepam)1. INITIAL _______monthly visits are required for management of these medications andrefills of the medication prescribed will be given on a monthly basis. Failure to performmonthly visits would result in slow tapering and ultimate discontinuation of medicationsand possible discharge from our practice2. INITIAL _______Medications will ONLY be prescribed by OUR practice (SP)and NO outside provider You must be aware that “doctor shopping” is an unacceptablebehavior. You hereby agree that you will limit any prescriptions for any and allopioids/benzos to the providers at SP. Only our providers will determine the dose ofyour medication and you understand that you may not under any circumstances adjust yourown dose. If we at SP decide to discontinue the use of controlled meds, the we willfollow you through the tapering off period and the YOU the patient will agree torecommendations made by the us.3. INITIAL _______YOU, the patient must report significant side effects from yourmedication/s. IF YOUR PHYSICIAN ISNT IN THE OFFICE AND SIDE EFFECTS GET WORSE YOU NEED TO GO TO THE EMERGENCY ROOM.4. INITIAL _______You understand that developing addiction is also possible by usingthese medications. Addiction is when patients take medications outside of the prescriptionor begin to find extra medications from other doctors or other sources or use these meds togain a high or relief (“the pathologic pursuit of reward or relief”). You must immediatelymake us aware if YOU, the patient start to use the medication differently from how weprescribed it, if you feel mental numbness or euphoria, if you experience drug cravings forthe drug, if it seems like the drug is wearing off. If this happens we may need to taper themedications. If there is any failure to follow medication monitoring procedures we maydischarge you from our practice.5. INITIAL _______Tolerance is also a condition which can occur with the use ofthese medications. This is defined as a need for higher doses to maintain the samecontrol. We will attempt to avoid tolerance by using other medications in conjunctionwith your benzo medication. If tolerance to these meds becomesunmanageable, the medication will be discontinued.6.INITIAL _______Use of this medication is only designed for the individual on theprescription bottle. You will never give your medications to others. Failure to complywill lead to discharge from our practice.7. INITIAL _______YOU the patient are informed that you should not stop taking themedications abruptly. If you feel you wish to stop these medications you MUST call or email (admin@) us the SAME day ,but do not self-adjust. If this happens, withdrawal symptoms may occur 24-48 hours after the last dose.Withdrawal symptoms may last from days to weeks. YOU must plan accordingly for your refills and allow at least 4-7days.8. INITIAL _______While you are on these medications you MUST follow the ourdirections and not change your dosage on your own. Adjusting your own medication mayresult in discharge from our practice.9. INITIAL _______The medications should be taken as prescribed. Medicationsshould be taken whole and are not to be broken (unless specifically noted on theprescription), chewed, or crushed. You must bring your pills with you to each appointment. You also will be subjected to random urine drug screens and pill counts.10. INITIAL _______All female patients should notify the physician if they arepregnant or possibly at risk to become pregnant. It should be known that childrenborn when the mother is on these medications will likely be physically dependent atbirth. You MUST call /email us immediately (admin@) when pregnancy is discovered. You MUST NOT adjust your medication dose on your own under anycircumstances.11. INITIAL _______If there is any evidence of drug hoarding, acquisition of drugsfrom other physicians, uncontrolled dose escalation or other aberrant behavior, youmay be discharged from our practice.12.. INITIAL _______I HEREBY ATTEST THAT THIS FORM GIVEN TO ME AND I READ IT IN FULL AND THAT I AM COHERENT AND ABLE TO UNDERSTAND THIS FORM. SIGNATURE OF PATIENT: _________________________________________________DATE: _________SIGNATURE OF PHYSICIAN: ____________________________________DATE: _________SIGNATURE OF PRACTICE MANAGER: __________________________________DATE: _______ ................
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