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A Community Reinforcement Approach: Treating Cocaine Addiction



Exhibit 29: Disulfiram Consent Form

By accepting disulfiram therapy, I acknowledge the need for assistance in solving a drinking problem. I also understand that, with my full cooperation in this therapy, I am most likely to achieve successful recovery. It has been explained to me and I understand the effects which disulfiram can trigger if I should consume even a small amount of alcohol in any form. These symptoms include flushing, nausea, vomiting, thirst, low blood pressure, and possible convulsions. I understand the this reaction may occur up to 2 weeks after I discontinue disulfiram. It has also been explained to me that the safe use of this drug in pregnancy has not been established. I understand that sexually active women taking disulfiram should be practicing a medically effective, reliable method of birth control. I understand that if I were to become pregnant, it is recommended that I terminate disulfiram therapy.

Signature:

________________________________

Witness:

________________________________

Date:

________

 

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