THE TELEMEDICINE USER receiving benzodiazepine medication) has agreed to use this medication as part of my treatment.
My provider is prescribing this medication to me for a diagnosis of:
Anxiety and other medically necessary treatments for my conditions.
I understand that the purpose of this medication is to treat the diagnosis listed above and ultimately improve my quality of life. Alternative therapies have been explained and offered, including the possible risks and benefits of other types of treatments that do not involve the use of benzodiazepines.
l am aware that the use of benzodiazepines has certain associated risks, including but not limited to the following:
- drowsiness
- poor concentration/confusion
- fatigue
- dreaming/nightmares
- dizziness
- impaired coordination
- stomach upset
- muscle weakness
- blurred vision
- memory loss
- depression
- abuse/death
- headache
- grogginess
- subtle personality changes
- psychological addiction
I will not be involved in any activity that may be dangerous to me or someone else while taking this medication. I am aware that benzodiazepines use slows reflexes and reaction time, increasing the risk of motor vehicle accidents. Activities that could be dangerous include, but are not limited to, operating heavy equipment or motor vehicles, working in hazardous environments, or being responsible for another individual who cannot care for themselves.
I am aware that tolerance can occur with the use of benzodiazepines. Tolerance is a need for a higher dose to maintain the same effect. Suppose my treating physician determines that continued dose escalation is not in my best interest. In that case, the benzodiazepine may need to be tapered and discontinued and may necessitate another form of treatment.
I understand that physical dependence is possible within a few weeks of starting benzodiazepine therapy. I am aware that physical dependence means that if my benzodiazepine use is markedly decreased, stopped, or reversed, I could experience a withdrawal syndrome (including but not limited to sweating, increased heart rate and high blood pressure, insomnia, abdominal cramps, tremors, diarrhea, muscle or bone aches, seizures), which may occur in 24- 48 hours of last dose. Withdrawal symptoms are usually self-limited but could, in rare cases, be life-threatening and may require hospitalization.
I understand that psychological addiction is a possible risk to the use of benzodiazepines. Addiction is recognized when an individual abuses a drug to obtain mental numbness or euphoria, when an individual shows a drug craving behavior, visits multiple doctors and pharmacies in pursuit of a medication or shows a manipulative attitude towards the provider to obtain the drug. Addictive behavior is the reason for the drug to be tapered and discontinued.
[checkbox] Females only: I understand that while on benzodiazepine therapy, I should maintain safe and effective birth control. If I plan to become pregnant or believe that I am pregnant while taking this medication, I will immediately notify my provider. I am aware that benzodiazepines cross the placenta, can cause congenital disabilities, and are therefore classified as class D teratogens. They may lead to the development of dependence and consequent withdrawal symptoms in the fetus. Benzodiazepines are excreted in
Breast milk is usually contraindicated in breastfeeding mothers.
All controlled substances must come from the provider whose signature appears below or, during their absence, by the covering provider unless specific authorization is obtained for an exception. I will tell my provider about all other medicines and treatments I receive.
Because these drugs have the potential for abuse, strict accountability is necessary when use is prolonged. I understand the importance of compliance with the rules outlined in this agreement to protect my access to controlled substances and to protect my provider’s ability to prescribe to me.