PM FORM 3.15.1 050106TMED.rtf - narbha 2026

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The document outlines a suggested format for obtaining informed consent from patients regarding psychotropic medication treatment. It details the information that must be discussed with the prescriber, including diagnosis, benefits, risks, alternatives, and the patient's rights to participate in their treatment and withdraw consent. The form includes sections for documenting discussions about each medication and requires signatures from both the patient or guardian and the prescriber.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the person's name and ID number at the top of the form. This information is essential for identifying the patient.
In the section regarding medications, list each medication along with its target symptoms. Ensure you specify symptoms rather than diagnoses for clarity.
For each medication, indicate how it was discussed (e.g., in-person, telephone, telemedicine) by checking the appropriate boxes.
Have the person or guardian provide their initials and date next to each medication listed, confirming their understanding and consent.
The prescriber should also initial and date next to their respective entries, ensuring all parties are informed and in agreement.
Finally, ensure that both signatures are obtained at the bottom of the form before saving or exporting your completed document.

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