Current Patient Forms

Electronic Signature: Type your name below *

Patient Name: *

I acknowledge and accept the above risks *

Yes I would like to move forward with the patient receiving the above treatment while acknowledging and accepting the risks outlined above

For Opioid Medications: The American Geriatrics Society, in concordance with numerous professional organizations, since 1991 publishes "Beers Criteria" every year. This is a list of medications that should be avoided in older adults and are called potentially innaporiate medications or "PIM"s because of their risk of causing harm. Opioid medications cause extreme constipation, sedation, immobility, poor balance, and increase the risk of falls and life threatening injuries. Additionally, opiods are a controlled substance because of their potential to become addictive. Please check all of the below boxes to acknowledge:

I acknowledge that this medication is on the list of medications that should be avoided in older adults

I acknowledge that this medication will increase the patient's risk of becoming extremely constipated

I acknowledge that this medication will increase the patient's risk of sedation

I acknowledge that this medication will increase the patient's risk of immobility and balance problems

I acknowledge that this medication will increase the patient's risk of falls and life threatening injuries

I acknowledge that this medication will increase the patient's risk of becoming addicted to this medication

For Muscle Relaxers: The American Geriatrics Society, in concordance with numerous professional organizations, since 1991 publishes "Beers Criteria" every year. This is a list of medications that should be avoided in older adults and are called potentially innaporiate medications or "PIM"s because of their risk of causing harm. Muscle Relaxers cause sedation, immobility, poor balance, and increase the risk of falls and life threatening injuries. Please check all of the below boxes to acknowledge:

I acknowledge that this medication is on the list of medications that should be avoided in older adults

I acknowledge that this medication will increase the patient's risk of sedation

I acknowledge that this medication will increase the patient's risk of immobility and balance problems

I acknowledge that this medication will increase the patient's risk of falls and life threatening injuries

Phone *

I am requesting that the above named patient be prescribed the following treatment *

Address *

Email *

For Antiinflammatory Medications: The American Geriatrics Society, in concordance with numerous professional organizations, since 1991 publishes "Beers Criteria" every year. This is a list of medications that should be avoided in older adults and are called potentially innaporiate medications or "PIM"s because of their risk of causing harm. Antiinflammatory medications suppress the immune system, cause bleeding, kidney damage, worsen or cause cardiovascular (heart and blood vessel) disease. Please check all of the below boxes to acknowledge:

I acknowledge that this medication is on the list of medications that should be avoided in older adults

I acknowledge that this medication will increase the patient's risk of infections

I acknowledge that this medication will increase the patient's risk of kidney damage

I acknowledge that this medication will increase the patient's risk of or worsening of cardiovascular disease

I acknowledge that this medication will increase the patient's risk of bleeding and blood loss

I acknowledge that I am authorized to make medical decisions for the above named patient *

Yes, I am the patient

Yes, I am the patient's Healthcare Power of Attorney

Yes, I am the patient's legal guardian

Date and time *

I acknowledge that https://www.healthinaging.org is the American Geriatric Society's patient and family education forum for more information for rationale and alternative treatments *

Yes, I acknowledge access to this resource

For Psychotropic Medications: The American Geriatrics Society, in concordance with numerous professional organizations, since 1991 publishes "Beers Criteria" every year. This is a list of medications that should be avoided in older adults and are called potentially inappropriate medications or "PIM"s because of their risk of causing harm. Psychotropic medications cause sedation, immobility, poor balance, and increase the risk of falls and life threatening injuries. Please check all of the below boxes to acknowledge:

I acknowledge that this medication is on the list of medications that should be avoided in older adults

I acknowledge that this medication will increase the patient's risk of sedation

I acknowledge that this medication will increase the patient's risk of immobility and balance problems

I acknowledge that this medication will increase the patient's risk of falls and life threatening injuries

Name of person filling out this form: *