Treatment Maintenance Form

Because the risk of vision loss increases over time with continued use, it is essential to assess a patient's response to Sabril early and determine that the benefit in treating the patient's seizures with Sabril is clinically meaningful and outweighs the risk of continued therapy with it.

You are therefore asked to attest to the following:

That you have assessed your patient's response to Sabril
That you have discussed the benefits and risks of continued Sabril therapy with the patient, parent, or legal guardian
That you have determined in your professional judgment that the benefit of controlling seizures exceeds the risk of vision loss
That continued Sabril therapy is appropriate and warranted

I have evaluated my patient's clinical response to the recent initiation of Sabril treatment and have verified a clinically meaningful improvement in seizure control.
I have determined that the benefit of Sabril treatment outweighs the risk of vision loss at this time. I recommend that my patient continue maintenance therapy with Sabril.

Patient Name (First, Middle, Last): *

Patient DOB:	*
	mm/dd/yyyy

Prescriber Name: * Prescriber NPI #:

Prescriber Signature:		Date:
			mm/dd/yyyy

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