Informed Consent Order Form - Mental Health

Patient Name: _____________________________________________________
Patient DOB: _____________________________________________________
Provider Name: _____________________________________________________

Please Obtain Informed Consent for the Following:

   Possible Only
Acamprosate Calcium Treatment (13634)
This treatment involves taking medicine called acamprosate. This medicine helps you avoid drinking alcohol. It works best when used with other...
Antabuse Treatment (13039)
This treatment involves the use of medication to reduce patient use and reliance on alcohol. During the treatment period, the patient is...
Antipsychotic Medication Treatment (13055)
This treatment involves taking an antipsychotic medicine. This medicine is used to help treat schizophrenia and certain other psychiatric...
Brain - Transcranial Magnetic Stimulation (TMS) for Depression (17746)
This procedure involves using magnetic pulses to stimulate, or excite, the neurons in your brain. Neurons are the cells in your brain that...
Buprenorphine Treatment (13665)
Buprenorphine can be administered alone or in combination with another drug called naloxone for treatment of opiate dependency. Treatment...
Cranial Electrotherapy Stimulation (CES) (20062)
This procedure involves giving a mild electric current to the head. Your doctor will place clips to your earlobes or behind your ears. The...
Electroconvulsive Therapy (ECT) (Index) (5225)
This procedure involves using electricity to produce seizures in your brain. Although this treatment may provide temporary or longer-term relief...
Electroconvulsive Therapy (ECT) (Maintenance) (19675)
This procedure involves using electricity to produce seizures in your brain. Although this treatment may provide temporary or longer-term relief...
Estrogen Therapy - Male to Female Transition (19772)
This procedure involves taking a hormone called estrogen. Estrogen is a sex hormone. It helps with the development of female sexual...
Ketamine Infusion Therapy for Depression (21080)
This procedure involves infusing ketamine into a vein to treat depression. This medicine is FDA-approved as an anesthetic. Its use for your...
Methadone Treatment for Narcotic Dependence (13038)
This treatment includes taking a medicine called methadone. Methadone is a medicine used to treat addiction to opiates. Opiates are also known as...
Naltrexone Treatment (13040)
Naltrexone is used to treat alcohol dependence or narcotics addiction. Naltrexone is taken either as an oral medication as often as once or...
Narcotics and/or Alcohol Dependency Treatment (12390)
This treatment entails the use of medication to reduce patient use and reliance on alcohol or narcotics. During the treatment period, the...
Prolonged Exposure Therapy (20208)
This therapy involves repeated exposure to activities, behaviors, thoughts, feelings, and situations. This will help to decrease stress about...
Varenicline Treatment (17666)
Varenicline is used to help you stop smoking. Varenicline is used as an alternative to nicotine replacement therapies. Before starting your...

Additional Notes (include Anatomical Side/Location if Applicable):

Order Form Accurate Until 7/19/2021