Berline Frye, AGNP-BC, PMHNP-BC BERC Medical and Behavioral Health Services LLC

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Berline Frye, AGNP-BC, PMHNP-BC BERC Medical and Behavioral Health Services LLC

Benzodiazepines Consent Form
Email: info@berchealthservices.com

This document is an agreement between patient and provider at BERC Medical and Behavioral Health Services LLC regarding the use of benzodiazepines, a class of medications that are used to treat a variety of conditions including anxiety, insomnia, muscle spasticity, convulsive disorders, as well as detoxification from alcohol and other substances. This document establishes clear guidelines for the safe use of these medications.

IN THE SPACES BELOW PLEASE PROVIDE YOUR NAME, DATE OF BIRTH, AND THE MEDICATION YOU ARE BEING PRESCRIBED

I (your name)

Date of birth

YYYY

have agreed to use this medication as part of my treatment. My provider is prescribing this medication to me for a diagnosis of: _____________________________________________________________________________

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