PM FORM 3151 -08-01-04 - Northern Arizona Regional - narbha-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the person's name and ID number at the top of the form. This information is essential for identifying the patient.
3. In the medication section, list each medication prescribed along with its target symptoms. Ensure you specify symptoms rather than diagnoses.
4. For each medication, indicate how it was discussed (e.g., in-person, telephone, tele-medicine) by checking the appropriate box.
5. The person or guardian should initial and date next to each medication listed, confirming their understanding and consent.
6. The behavioral health medical practitioner must also initial and date beside their printed name after discussing the medications.
7. Finally, ensure that all signatures are collected and that a copy of this informed consent form is stored in the patient's file as required.

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