I hereby agree to take Antabuse on prescription of Dr. Edwards in the belief that it will be useful in the treatment of my problem of alcoholism.
The method of taking Antabuse has been explained to me by Dr. Edwards, and I understand the method to be one tablet daily by mouth. The effects of taking alcohol in any form while taking Antabuse have been explained to me. I realize that no form of alcohol may be taken for as long as 14 days after the last dose of Antabuse and that antabuse may not be taken for at least 24 hours after my last exposure to alcohol. I further realize that the consequences of taking alcohol, even in small amounts, during this period would be the Antabuse-alcohol reaction. This reaction is understood by me to produce flushing, throbbing in head and neck, headache, quick rapid breathing, nausea and vomiting, fainting, sweating, thirst, chest pain, rapid heart rate, weakness, confusion, blurred vision, dizziness, and drop in blood pressure.
I am aware that, in addition to the common forms of alcohol (beer, wine, whiskey, gin, etc.), alcohol is present in many common household items, such as mouthwashes, cough medicines, shaving lotions, vinegars and salad dressings with wine, tonics and elixirs, hair tonics, communion wine, gourmet food cooked with brandy or wine, nasal sprays, many liquid medications (e.g. paregoric), food extracts (lemon, vanilla), rum cake, and rubbing alcohol. None of these may be safely ingested.
I agree to take Antabuse for an agreed upon period of months and to continue its use until I have discussed stopping with Dr. Edwards (provided there are no adverse effects). I am aware that consumption of large amounts of alcohol within 14 days of the last dose of Antabuse can produce a severe Antabuse-alcohol reaction, causing unconsciousness, marked trouble breathing, convulsions, heart attack, and circulatory failure - any of which could lead to a serious medical emergency. I have been advised to carry an identification card indicating that I am on Antabuse or to wear an identification bracelet with the same information. I have also been advised to inform my relatives and friends of the fact an to instruct them regarding the symptoms of the Antabuse-alcohol reaction. It is understood that a physician should be consulted immediately upon the development of any of these symptoms.
Dr. Edwards has explained the side effects of Antabuse taken alone, which include sleepiness, lethargy, acne-like skin eruptions, loss of interest in sex, garlic taste, depression, and, when taking Antabuse over long periods of time, confusion, and numbness and tingling sensation in the legs. (Any of the above symptoms should be quickly reported to a physician.) I understand the nature of the proposed medication, attendant risks, and expected results, as described above, and hereby request such treatment.