55 / 60
surement, will be monitored with regard to possible side effects. If side effects are seen, the medication will be discontinued.
The medication named PROPRANALOL is produced as tablets in Turkey to be used for adults. During the course of
hemangioma treatment of your child, the medication will be given orally, the dosage (the amount of medication to
be given) will be designated regarding the kilogram of your child as required. Nevertheless, during the course of
medication use, a dose readjustment may be required due to alterations of kilogram of your child. The treatment
duration can vary according to patient. You will be notified about dosage to be used and probable duration prior to
the treatment.
PROPRANALOL is used in hemangioma treatment for several years. There is great deal of scientific information
about the use to be safe and effective. Nevertheless, in the user manual and prospectus (the guide in the medica-
tion box) of the medication in Turkey, the use for this purpose is not mentioned. Legally, the use of medications for
the purpose of treatment methods that are not in the guides in Turkey is only possible by dispention of the family.
Therefore we ask your permission for use of the medication in the treatment of hemangioma as it is described above.
(The standard sections of consent form such as signatures, special statement sections are in the continuing section of the form.)
55