Informed Consent Form for administration of Disulfiram
Patient’s Name: Mr Padmanabh Bharti
Age: 49 years
Relative’s Name: Mr Bhartia Relation: Father
Information
Disulfiram is a medicine useful for abstaining from alcohol consumption.
1. The body is not able to process alcohol while taking Disulfiram. It is important to avoid
alcohol in any form like perfumes, deodorants, hand sanitizer, food items (dressings,
vinegars, marinades, sauces, extracts, etc.) and alcoholic beverages.
2. Disulfiram should NOT be taken if you have consumed alcohol within the past 12 hours.
3. A Disulfiram-alcohol reaction may include: redness of the face, itching, burning, trouble
breathing, throbbing pain in head and neck, nausea, vomiting, sweating, thirst, palpitations,
weakness, dizziness, blurred vision and confusion. Severe reactions may involve respiratory
failure, heart failure, unconsciousness, convulsions and death.
4. The larger the dose of the alcohol, the stronger the Disulfiram-alcohol effect. The reaction
can last from 30 minutes to several hours, or as long as it takes for the alcohol to be
metabolized.
5. Disulfiram-alcohol reaction may occur for up to 2 weeks after stopping medication.
6. The side effects which may occur in some patients on Disulfiram are drowsiness, numbness
in extremities, metallic taste and/or allergic skin reaction. Liver damage is an uncommon
reaction.
7. Tell your doctor or seek emergency care if you develop any of these symptoms:
Yellowing of the skin or eyes
Dark urine
White stool or diarrhoea
Stomach pain or loss of appetite
More tired than normal
8. Allergic reactions can happen when taking Disulfiram. Consult your doctor or get immediate
medical help if you have any of these symptoms:
Skin rash
Chest pain
Trouble breathing or wheezing
Dizziness or fainting
Swelling of eyes, mouth, tongue, or face
9. Whenever you visit another speciality doctor for treatment of other illness, please inform that
doctor that you are taking Disulfiram.
10. Disulfiram is only one part of your treatment. It is important that you attend Alcoholic
Anonymous meetings and therapy along with the medical part of your treatment to assist you
in your recovery process.
Consent for Disulfiram Treatment
I declare that I am more than 18 years of age.
I agree to the procedure of course of treatment described on this form.
I understand that I will have the opportunity to discuss any concerns I have.
I have been explained about the following in the best possible language I understand and have
understood the same. I had the opportunity to clear all my doubts.
I. Diagnosis: Alcohol Dependence syndrome with Mood disorder
II. Nature of treatment: Medication and therapy + Lifestyle changes
I have signed this consent voluntarily out of my free will without any pressure and in my full
sense.
Signature of Patient:
Date:
Thumb Impression (if not signing)
(In case of male Right thumb and for Female Left thumb impression to be taken)
Signature of doctor:
Dr Era Dutta
18/03/2024
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INFORMATION TO TREATING DOCTOR
The patient is on Alcohol -De-addiction (Disulfiram) Therapy; please don't give him any
syrup containing alcohol. If he taken alcohol while on this Therapy, he develops.
Nausea, Vomiting Hypotension, Giddiness Itching, Rash
Please give him:
IV Fluids, 1 bottle of DNS+RL. Additional Fluids as when needed.
*IV Inj. Vit C
IV Inj. Avil 1 Amp
IV Inj. Effcorlin 1 Amp
IV Inj. Domperidone 1 Amp
Monitor B. P. If B.P. falls significantly, refer to nearest physician for further
management.
