In case of emergency (if different than above)

PAIN MEDICINE POLICY

These are our established guidelines for pain medications:

1.  A copy of the prescription you were given will be photocopied and placed in your chart.
2. To acquire medication refills, you must notify our office between the hours of 9:00 AM – 3:00 PM, Monday through Friday (except Holidays).  It may take up to TWO working days to call in medications.
3. After hours and on weekends, the doctor on call WILL NOT call in any additional prescriptions or refill any medications.
4. The doctor on call will only answer questions regarding complications from medications or from procedures.
5. If a prescription is stolen or lost, a refill will not be given until the date it was to be refilled.  THERE WILL BE NO EXCEPTIONS.
6. Use of prescriptions more often than prescribed will not be refilled early.
7. It is your responsibility to inform our physician of any medications you are receiving from any other physicians.
8. AUTOMATIC DISCHARGE FROM THE PRACTICE WILL OCCUR FOR ANY OF THE FOLLOWING REASONS:
   … forgery or diversion of the prescriptions.
   … failure to comply with recommendations of the physician.
   … drug-seeking behaviors such as using medication more than recommended
   … repeatedly calling the physician after hours
   … repeated visits to the ER for pain
   … persistent use of pain medications beyond the expected postoperative period
   … failure to notify the physician that you are receiving medications from other physicians.
    
   You may be referred to a Pain Management Specialist or asked to have an evaluation by a Psychiatrist or Psychologist to help manage your pain.
    
   I have read and understand the above pain medication policy.

The following is an authorization for miscellaneous services this office uses. We will make every effort to abide by your instructions. Please provide the following information:

Appointment Reminders/ Test Results (laboratory, x-rays, etc.):
If we need to reach you regarding an appointment or test results, we will make every effort to reach you personally. If we cannot reach you personally, we will only leave a message asking you to call our office during regular business hours. Please check all items below that apply to you.