Clinical
Programs: Stop
Smoking Now
Consent
for Anti-Smoking Treatment
I, _______________________ have requested that
Dr. Kochan treat me for nicotine addiction.
I understand that although this treatment has
been used in many clinics it is not yet accepted
as a “traditional” treatment by many
physicians and is considered experimental.
I understand that this treatment consist of
a series of three injections over a thirty minute
period of time using three standard medications,
and as with any invasive procedure there are
associated risks.
The most common side effects are dry mouth,
blurred vision, fatigue and drowsiness for
up to 24 hours. Other possible side effects,
although unlikely, include disorientation,
memory disturbances, dizziness, restlessness,
confusion and hypotension.
Dr. Kochan has explained the possible risks
and common side effects of this treatment in
addition to the inherent dangers associated
with cigarette smoking.
I certify that I have read and, and fully understand,
the above paragraphs, and that I have had sufficient
opportunity to ask questions.
I also certify that I have given a complete
and honest history of all medications and medical
conditions.
Patient Signature____________________________
Date___________
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