Consent Elements

Medication, supplement, allergy, contraindication, pregnancy/lactation, and condition-specific interaction screen completed.

Patient signature and date:

Clinician signature and date:

Witness signature and date (if required):

Plan and Follow-Up

Focus	Documentation
Consent review	Summarize supplement rationale, benefits, material risks, alternatives, and uncertainty. Rationale / benefit: Risks / alternatives: Medication/supplement/allergy/pregnancy-lactation contraindications:
Questions answered	Record patient questions, education, teach-back, and voluntary acknowledgement. Questions: Teach-back: Voluntary acknowledgement:
Follow-up	Set monitoring, stop criteria, and next review date. Monitoring: Stop criteria: Follow-up:

Focus

Documentation

Consent review

Summarize supplement rationale, benefits, material risks, alternatives, and uncertainty.

Rationale / benefit:

Risks / alternatives:

Medication/supplement/allergy/pregnancy-lactation contraindications:

Questions answered

Record patient questions, education, teach-back, and voluntary acknowledgement.

Questions:

Teach-back:

Voluntary acknowledgement:

Follow-up

Set monitoring, stop criteria, and next review date.

Monitoring:

Stop criteria:

Follow-up: