Treatment with Controlled Substances: Patient Agreement

I will keep (and be on time for) all my scheduled appointments with the doctor.

I will participate in all other types of treatment that I am asked to participate in.

I will keep the medicine safe, secure and out of the reach of children. If the medicine is lost or stolen, I understand it will not be replaced until my next appointment, and may not be replaced at all.

I will take my medication as instructed and not change the way I take it without first talking to the doctor.

I understand that prescriptions will be filled only during scheduled office visits with the doctor.(Exceptions may apply)

I will make sure I have an appointment for refills. If I am having trouble making an appointment, I will tell a member of the office immediately.

I will treat the staff at the office respectfully at all times. I understand that if I am disrespectful to staff or disrupt the care of other patients my treatment will be stopped.

I will not sell this medicine or share it with others. I understand that if I do, my treatment will be stopped.

I will sign a release form to let the doctor speak to all other doctors or providers that I see.

I will tell the doctor all other medicines that I take, and let him/her know right away if I have a prescription for a new medicine.

I will not get any opioid pain medicines or other medicines that can be addictive such as benzodiazepines (klonopin, xanax, valium) or stimulants (ritalin, amphetamine) without telling my provider of the treatment team before I fill that prescription. I understand that the only exception to this is if I need pain medicine for an emergency at night or on the weekends.

I will not use illegal drugs such as heroin, cocaine, marijuana, or amphetamines. I understand that if I do, my treatment may be stopped.

I will come in for drug testing and counting of my pills within 24 hours of being called. I understand that I must make sure the office has current contact information in order to reach me, and that any missed tests will be considered positive for drugs.

I will keep up to date with any bills from the office and tell the doctor or member of the office immediately if I lose my insurance or can't pay for treatment anymore.

I understand that I may lose my right to treatment in this office if I break any part of this agreement.