Patient Consent Form for Treatment with Low Dose Naltrexone (LDN)

LDN does have a license from the UK and European medicines regulatory organisations but it does not cover your condition and so the drug is not allowed to be promoted or marketed within the UK for your condition. Although the drug cannot be marketed, it can still be used off-label and there is evidence to support its use on specific conditions, such as yours.

The purpose of LDN medication is to alleviate symptoms of your chronic condition. The drug may benefit you by reducing your symptoms caused by chronic inflammation and by regulating other immune responses. Please be aware that LDN is generally a long-term treatment requiring monitoring by the speKTrum health team at agreed intervals to ensure safe repeat prescribing. There is no guarantee that it will benefit or cure any disease.

Potential side effects that you may experience include; sleep disturbance (nightmares, insomnia, vivid dreams), gastrointestinal symptoms (abdominal cramps, diarrhoea, constipation), headaches, flu-like illness, agitation or dizziness, very rare elevated liver enzymes and reduction in renal function.

This assessment and advice should not be looked at as taking over the role of a GP or orthodox specialist. LDN is a medicine that can usually be taken in addition to your existing or proposed treatment. We are not suggesting that you take LDN instead of any other treatment that you are offered. We strongly encourage you to share this information with your health care providers. We confirm we are very happy to liaise directly with your health care providers with your consent, to provide an integrated approach.

PATIENT CONSENT

By completing and signing the form below you confirm that you understand Low Dose Naltrexone (LDN) is not licensed for marketing in this country for your condition and that you consent for it to be used as part of your treatment plan and that the doctor supervising this treatment has satisfactorily answered all of the questions you have about this medication and its status.

Once completed and sent, you will receive an immediate response confirming receipt of your consent. If you do not receive this confirmation, please check your junk mail or you may send the consent form again making sure that you have typed your email address correctly.

We look forward to being of service to you.

 


 
Today's Date: 05/06/2020

Your Full Name (required)

Your Email (required)

Please use your mouse or screen to write your signature below

captcha
For security, please type the above content here: