Healthcare GABA Form

Healthcare GABA Form

Patient Information

Male Female Other / Prefer not to say

Emergency Contact

Insurance Information

Medical History & Current Status

Please indicate if you have ever been diagnosed with or experienced any of the following (check all that apply):

Seizure disorder
Depression or mood disorder
Substance use disorder
Liver disease or abnormal liver tests
Kidney disease
Cardiac disease or arrhythmia

GABA Therapy Details, Risks, and Alternatives

I understand that GABA (gamma-aminobutyric acid) therapy, whether administered as an oral supplement, compounded product, or by other route, is intended to provide neuromodulatory effects. The potential benefits, known risks, and reasonable alternatives have been explained to me by the provider.

Known and reasonably foreseeable risks include but are not limited to: excessive sedation, dizziness, impaired coordination, interaction with central nervous system depressants (including benzodiazepines, opioids, alcohol), hypotension, allergic reaction, gastrointestinal discomfort, and unknown long-term effects. In rare cases, adverse events requiring medical intervention may occur.

Reasonable alternatives to GABA therapy, as applicable, include non-pharmacologic therapies, alternative supplements or medications, referral to specialty care, or no treatment. I have had the opportunity to ask questions and those questions have been answered to my satisfaction.

Contraindications, Precautions & Testing

I confirm the following (check all that apply):

I am pregnant, breastfeeding, or trying to conceive
I am taking an MAOI or other contraindicated medication
I currently take benzodiazepines, opioids, or other CNS depressants
I have liver or kidney impairment
None of the above / no known contraindications

For individuals who are pregnant or of childbearing potential, pregnancy testing may be required prior to initiation. I consent to any testing deemed necessary by the treating provider as a condition of treatment.

Authorization, Release, and Acknowledgments

By signing below I authorize the administration and/or prescription of GABA therapy as described above by the treating provider or designated clinical staff. I authorize the release of relevant medical information to other healthcare providers and to my insurer for purposes of treatment and billing. I understand that this authorization is voluntary and may be revoked in writing at any time, except to the extent action has already been taken in reliance on it.

I acknowledge that no guaranteed results have been promised and that unanticipated complications may occur. I agree to follow provider instructions regarding dosing, concomitant medications, activity restrictions, and follow-up care. I will immediately report any adverse effects or unexpected symptoms.

Authorization expires on:

HIPAA Acknowledgment: I acknowledge that I have received or been offered a copy of the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed, and my rights regarding that information. I authorize disclosure of my health information as necessary for treatment, payment, and healthcare operations related to GABA therapy.

Patient Certification: I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand that providing false or incomplete information could affect my safety and the appropriateness of GABA therapy.

Authorization to Contact and Follow-Up

I authorize the provider to contact me via the phone number(s) and email listed on this form for appointment reminders, clinical follow-up, and to discuss test results or adverse events related to GABA therapy. I understand standard messaging risks and may revoke this consent in writing.

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