I confirm that: *

Tick each box if you agree with the statement

Prescriber Dr Athina Zakynthinaki has explained the benefits and possible side-effects of using Methylphenidate to treat ADHD and I have understood the explanation.

I have been given a patient medication leaflet.

Prescriber Dr Athina Zakynthinaki has discussed treatment options with parents.

I have had enough time to consider my decision and to ask questions. I understand that this medication is being prescribed within its licence.

I consent my child to being treated with the above medication.

I understand I can withdraw or give my consent at any time, and I will inform the prescriber.

Date *

MM

DD

YYYY

Patient Name *

First Name

Last Name

Parent's Name *

First Name

Last Name