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comfortable by relieving my symptoms and do not address any underlying infection. My decision about continued treatment may depend on a number of factors and the importance of these factors to me.  Some of these factors include (a) the severity of my illness and degree to which it impairs my quality of life, (b) whether I have co-infections, which can complicate treatment, (c) my ability to tolerate antibiotic treatment and the risk of major and minor side effects associated with the treatment, (d) whether I have been responsive to antibiotics in the past, (e)  whether I relapse or my illness progresses when I stop taking antibiotics, and (f) my willingness to accept the risk that, left untreated, a bacterial infection potentially may get worse.

For example, if my illness is severe, significantly affects the quality of my life, and I have been responsive to antibiotic treatment in the past, I may wish to continue my treatment.  However, if I am willing to accept the risk that the infection may progress or if I am not responsive to antibiotics, I may wish to terminate treatment. I will ask my doctor if I need any more information to make this decision and am aware that I have the right to obtain a second opinion at any time if I think this would be helpful.

I realize that the choice of treatment approach to use in treating my condition is mine to make in consultation with my physician.  After weighing the risks and benefits of the two treatment approaches, I have decided: (CHECK ONE)

To treat my Lyme disease through a

treatment approach that relies heavily on

clinical judgment and may use antibiotics

until my clinical symptoms resolve. I recognize

that this does not conform to IDSA guidelines   Not to pursue antibiotic therapy

treatment approach and that insurance companies may

not cover the cost of some or all of my treatment.

Only to treat my Lyme disease with

antibiotics for thirty days, even if I still  

have symptoms

I may obtain a copy of both the IDSA and ILADS

guidelines by specifically requesting a copy from

my physician to aid my decision.  I choose not to obtain

a copy at this time.

To my knowledge, I am not allergic to any medications except those listed below:

I understand the benefits and risks of the proposed course of treatment, and of the alternatives to it, including the risks and benefits of foregoing treatment altogether.  My questions have all been answered in terms I understand.  All blanks on this document have been filled in as of the time of my signature.

Signature:     ________________________________ Date: _____________________

Print Name: ________________________________Witness:_____________________             

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