* = Required Information
SUBMIT TO MEDICAL FOR COMPLETION
INFORMED-CONSENT FOR MEDICATION FORM
This consumer is:
  An adult without court-appointed guardian of the person.
(Continue immediately below, using A. CAPACITY)
  A minor or adult with court appointed guardian of the person, and consent can be obtained from the parent or legal custodian of a minor or the guardian of an adult.
(Continue below, using B. INFORMED CONSENT TO PSYCHOTROPIC MEDICATION)
A. CAPACITY
I,   have examined    to determine whether this person has the capacity to understand and appreciate the nature and consequences of his/her actions, including the likelihood of therapeutic benefit of medication and the risk of side effects and possible treatment alternatives, and I find that he/she:
  Does have mental and physical capacity and is willing to consent.
(Continue below with B. INFORMED CONSENT TO PSYCHOTROPIC MEDICATION)
  Does have mental and physical capacity and is unwilling to consent but is not unsafe.
(Comply with consumer’s right to decline medication.)
B. INFORMED CONSENT TO PSYCHOTROPIC MEDICATION

In general terms, I have discussed the above medication(s) with the consumer /parent/legal custodian/guardian. Expected results, common side effects, and possible risks were discussed and presented in a clear and reasonable manner consistent with his/her abilities of comprehension and understanding. Alternate treatments (including no treatment and its consequences) were also discussed. I also informed this person that he/she could refuse medication and/or could withdraw consent. I informed him/her that if such refusal would be unsafe to the consumer or others, the consumer may be medicated involuntarily. I have informed this person of his/her right to file a human rights complaint or to seek judicial protection of consumer’s rights or privileges by law.
WRITTEN CONSENT: The above-named physician explained the benefit(s) and the effects of the above medication(s).

I understand and consent to this medication as ordered by the physician and agree to report any changes in my/the consumer's condition. I also understand that I may refuse to take medication when it is offered and/or revoke consent at any time. I understand that if such refusal would be unsafe to the consumer or others, medication may be given involuntarily. I understand I have the right to file a human rights complaint or to seek judicial protection of consumer’s rights or privileges as provided by law.
ORAL CONSENT: If by anyone other than consumer, written consent must be obtained subsequently
I REVOKE MY CONSENT
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