Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
High-Risk Medication Consent Form
Your information
Patient Name *
Medication Name & Dosage
| Medication | Dose | How often |
|---|---|---|
Indication for Therapy
Contraindication Screening
REMS Enrollment Acknowledgment
Adverse Effects Acknowledged
Additional details
Monitoring Schedule Reviewed
Emergency Instructions Reviewed
Pregnancy Prevention Agreement
Medication Guide Received
| Medication | Dose | How often |
|---|---|---|
Patient Signature
Date
Prescriber Signature
Date
High-Risk Medication Consent Form template from formisoft.com. formisoft.com/intake-templates/high-risk-medication-consent