Healthcare Pharma Consent Form

HEALTHCARE PHARMA CONSENT FORM

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History

Are you pregnant or breastfeeding?   Yes    No

Medication / Treatment Details

Medication Name:    Dose:    Route:

Frequency / Schedule:    Indication / Purpose:

Prescribing Clinician:    Facility/Clinic:

Administration Date (if single date):    Lot / Batch Number (if known):

Administration Type:   Single dose    Series / multiple doses    Ongoing therapy

Risks, Benefits, and Alternatives

I have been informed of the intended benefits of the ordered medication and the reasonably foreseeable risks and side effects, which may include but are not limited to local irritation, allergic reaction, systemic adverse effects, and other complications. I understand that the clinician has explained the expected benefit and the material risks associated with receiving this medication.

Alternatives to this medication, including no treatment or alternate medications/therapies, have been explained to me and I have had the opportunity to ask questions and receive answers.

I acknowledge that no guarantee of outcome has been made. I understand that I may withdraw this consent at any time prior to administration without affecting my future care.

I confirm that I have informed the clinician of all medications, supplements, and health conditions that could interact with the medication. Initials:

Privacy, Release, and Authorization

I authorize the release of medical information necessary for the administration and billing of the medication, and I acknowledge receipt of the facility's privacy practices. I authorize the facility and prescribing clinician to discuss my relevant medical information with the persons below as necessary for care and coordination.

This authorization expires on:

HIPAA Acknowledgment: I acknowledge that I have been presented with a copy of the practice privacy notice and understand my rights regarding protected health information.

Emergency Treatment Authorization

In the event of an acute adverse reaction following administration of the medication, I authorize the clinician and facility staff to provide immediate emergency treatment as clinically necessary, including activation of emergency services. I understand reasonable attempts will be made to notify my emergency contact.

Consent to emergency treatment:   Yes    No

Voluntary Consent

By signing below, I certify that I am the patient named above or the patient's legally authorized representative. I have read and fully understand this consent form, have had the opportunity to ask questions, and voluntarily consent to the administration of the medication described above. I understand I may revoke this authorization in writing prior to administration but that revocation will not affect actions already taken in reliance on this consent.

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