Patient Disclosure

The following is a copy of the patient disclose and consent form you will fill out at clinic on your visit:

TO THE PATIENT: You have the right as a patient, to be informed about your condition and the recommended medical or diagnostic procedure, as well as the risks and hazards involved so you make an informed decision whether to undergo a medical procedure. This disclosure is provided as a means to protect your patient right to know.

ABOUT THE MEDICINES: Atropine and Scopolamine and anticholinergic drugs. That means they attach to cholinergic receptor sites, like nicotine, except they suppress the activity of these sites rather than stimulate them like nicotine. The medicines have been used in anesthesia before surgery to alleviate nausea, and assist in muscle relaxation, to decrease body secretions, and normalize heartbeat.

SIDE EFFECTS: Many side effects are temporary, lasting from 4 to 12 hours, and vary from patient to patient. Typical side effects - may include dry mouth, nose and throat, difficulty urinating, blurred vision, light-headedness and constipation.

Unusual side effects - In older adults, who are usually more sensitive than younger adults, and in the rare younger adult who may be hypersensitive to the effects of anticholinergics, temporary side effects may also include, drowsiness, confusion or memory loss, excitement, nervousness and restless ness, or irritability. Eye pain may be an indication of glaucoma.

CONSENT: I understand the benefits and risks of the ANTICHOLINERGIC MEDICINES and voluntarily request Green Leaf California and their physicians(s) and associates, technical assistants and other health care providers they may deem necessary, to treat my NICOTINE ADDICTION. I understand the following medical and/or diagnostic procedures are planned for me and O(we) voluntarily consent and authorize these procedures. I understand this procedure utilizes ANTI-CHOLINERGIC MEDICATIONS, ATROPINE and SCOPOLAMINE, POTENTIATED BY PHENERGAN WITH A CARRIER OF LIDOCAINE. These medications have been F.D.A. approved for a variety of applications other than smoking cessation and are not deemed as being addictive. I understand the physician may discover other or different conditions, which require additional or different procedures than those planned, or may in his best professional judgment not perform the treatment due to contraindications. I authorize the physician and such associates, technical assistants, and other heal care providers to perform other such procedures deemed necessary in their professional judgment. I understand no warranty or guarantee has been made to me as to result or cure, and that the procedure is ineffective in some patients, and there is a possibility I maybe part of that group.

I realize the risks and hazards associated with this particular procedure as referenced above, and that there is a potential for infection, blood clots, hemorrhage, idiosyncratic or allergic reaction.

I SHOULD NOT PARTICIPATE in the treatment if suffering from acute angle glaucoma, enlarged prostate, if pregnant, or taking any medicines or have any physical conditions that are referenced as contraindications in the medical questionnaire, or have knowingly answered incorrectly on the medical questionnaire.

My physician has adequately explained the treatment/procedure. I have been given an opportunity to ask questions about my condition, alternative forms of treatment, the risks of non-treatment, the procedure to be used and the risks and hazards involved. I believe sufficient information has been given in order to give my consent to treatment. I certify this form has been fully explained to me. I have read it or had it read to me and understand its contents.

The undersigned consents to any x-rays or laboratory examinations and medical treatment rendered he patient by the attending physician and by designated clinic personnel. These assistants I understand are not licensed physicians and may not treat or diagnose any illness, injury, or medical condition, and may only perform medical procedures under the supervision of a licensed physician. These assistants may include: Registered Nurses, Licensed Practical Nurses, Nurses Aids, Technicians, Radiology Technicians, and Medical Assistants, and other persons who are not licensed physicians, but who are deemed by the physician to be trained to assist under the general and special instructions provided by them. I further understand that I may revoke this authorization at any time during treatment.

With regard to the smoking cessation procedure, the patient understands and agrees that he/she WILL NOT OPERATION AN AUTOMOBILE FOR 12 HOURS, *IF THE PATIENT has followed all instructions and cooperated fully and completely concerning the smoking cessation treatment, should he/she return to smoking within their lifetime the patient may return for additional treatment. The clinic will provide the medicines and all necessary medical testing free of charge. The patient will be responsible for a $99.00 office visit charge.

Follow Up Medications:

I acknowledge receipt of information on prescribed medications that have been provided to me by the clinic.

Authorization for Release of Medical Information/Records:

I understand my contact information/medical records may be disclosed to Green Leaf California as part of my involvement in the smoking cessation program. I acknowledge I may be contacted by Green Leaf California , after my participation in the program as part of an inquiry into my "smoke-free" status. I authorize the disclose of this protected information for the sole purpose of my involvement in the program and subsequent determination of its success. I acknowledge the right to revoke this authorization in writing to either my physician or Green Leaf California.