Consent/ Refusal/ For Vitamin K Administration

_______I/we have read the Merck Prescribing Information (Package Insert) of (AquaMEPHYTON® (Phytonadione) and have had opportunity to ask questions regarding my/our options for Vitamin K administration to my/our newborn baby.

_______I/we understand the risks (See package insert warning below) and alleged benefits of Vitamin K administration (both oral and injectable). As well as no Vitamin K administration. My/our choice for newborn Vitamin K administration is initialed below.

http://www.fda.gov/medwatch/SAFETY/2003/03Feb_PI/AquaMEPHYTON_PI.pdf

"WARNING - INTRAVENOUS USE Severe reactions, including fatalities, have occurred during and immediately after the parenteral administration of AquaMEPHYTON® (Phytonadione)."

______I/we are REFUSING Vitamin K administration to our baby.

______I/we choose to have our own form of supplemental Vitamin K given to our baby. He/She will receive an oral dose of supplemental Vitamin K after birth, and thereafter according to the instructions and directions of the manufacturer of the supplement.

______I/we choose to have the baby receive an oral dose of Vitamin K after birth, again at 1 - 2 weeks, and at one month of age.

______I/we choose to have the baby receive one injection of Vitamin K after the birth.

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Client's Signature

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Partner's Signature

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Midwife's Signature

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