Example Informed Consent for
Medication Administration Services
Name of Medication
Patient Information
Name
First Name___________________ Middle Initial____________Last Name______________________
Date of Birth _______/_______ /_______
Sex/gender: o Male o Female
Address
Street ___________________________________________________________________________
City_ ____________________________________________State___________Zip ______________
Home Phone______________________________________________________________________
Work Phone________________________________Mobile Phone_ __________________________
Caregiver/Other Contact
Name____________________________________________________________________________
Home Phone Number_______________________________________________________________
Work Phone Number_______________________________________________________________
Mobile Phone Number______________________________________________________________
Relationship to Patient______________________________________________________________
Primary Care Provider
Name____________________________________________________________________________
Office Phone Number_______________________________________________________________
Prescriber for Administered Medication
Name____________________________________________________________________________
Office Phone Number_______________________________________________________________
Insurance Information
Plan Name________________________________________________________________________
Policy/ID Number__________________Group Number____________________________________
Phone Number____________________________________________________________________
APhA Implementation Toolkit for Pharmacy-based Medication Administration Services
By my signature below, I consent to the administration of the prescribed medication by a
pharmacist or a supervised student pharmacist, where permitted by law, and to be contacted at
the phone number provided above regarding this pharmacy service. I also release the pharmacy
and agents from all liability, including acts of omission or commission, resulting or arising from my
receipt of this medication. I understand that:
n I have voluntarily chosen to receive the n I have had the opportunity to ask questions
medication. about the medication, and all my questions
n I am of legal age and authorized to execute have been answered. I understand the
this consent form. benefits and risks of the medication.
n I will immediately alert the pharmacist and n I understand that my receipt of this
the prescribing physician of any medical medication is subject to reporting, by my
conditions which may adversely affect pharmacy or its business associate, to my
my personal health or effectiveness of the primary care physician, the prescribing
medication. physician, and/or the manufacturer, if
required, and I authorize these disclosures.
n I have received education about potential
side effects of the medication, when they n I authorize the pharmacy to bill my
may occur, and when and where I should insurance provider for services.
seek treatment. I understand that if I n I understand that a copy of my medical
experience any side effects, I am responsible records will be stored in a confidential
for following up with my prescriber at my manner.
expense.
Patient
Print Name_ _________________________ Signature_______________________Date __________
(For Pharmacy Use Only)
Medication Name Lot Expiration Date Manufacturer Dose
Date of Administration Time of Administration Route of Administration Site of Administration
Signature of Pharmacist_____________________________________________________________
Date_____________________________________________________________________________
APhA Implementation Toolkit for Pharmacy-based Medication Administration Services
