| By accepting disulfiram therapy, I acknowledge the need for assistance in solving a drinking problem. I also understand that, with my full cooperation in this therapy, I am most likely to achieve successful recovery. It has been explained to me and I understand the effects which disulfiram can trigger if I should consume even a small amount of alcohol in any form. These symptoms include flushing, nausea, vomiting, thirst, low blood pressure, and possible convulsions. I understand the this reaction may occur up to 2 weeks after I discontinue disulfiram. It has also been explained to me that the safe use of this drug in pregnancy has not been established. I understand that sexually active women taking disulfiram should be practicing a medically effective, reliable method of birth control. I understand that if I were to become pregnant, it is recommended that I terminate disulfiram therapy.
Signature:
________________________________
Witness:
________________________________
Date:
________
|
