Patient Agreement Form for Controlled Substance Prescriptions

Patient Agreement Form for Controlled Substance Prescriptions

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Client Name *

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Agreement for Controlled Substance Prescriptions
The use of medication(s)* (print names of medication(s)) may cause addiction and is only one part of the treatment for condition(s)* (print the name of condition - e.g. pain, anxiety, etc.).
The goals of this medicine are:

to improve my ability to work and function at home. to help my aforementioned condition as much as possible without causing dangerous side effects.
I have been told that:
1. If I drink alcohol or use street drugs, I may not be able to think clearly and I could become sleepy and risk personal injury.
2. I may become addicted to this medicine.
3. If I or anyone in my family has a history of drug or alcohol problems, there is a higher chance of becoming addicted.
4. If I need to stop this medicine, I must do so slowly or I may become sick.
I agree to the following:
Refills
- I am responsible for my medicines. I will not share, sell, or trade my medicine. I will not take anyone else's medicine.
- I will not increase my medicine until I speak with my doctor or nurse.
- My medicine may not be replaced if it is lost, stolen, or used up sooner than prescribed.
- I will keep all appointments set up by my doctor (e.g. primary care, physical therapy, mental health, substance abuse treatment, pain management, etc.)
- I will bring the pill bottles with any remaining pills of this medicine to each clinic visit.
- I agree to give a blood or urine sample, if asked, to test for drug use.
I understand that refills will be made only during regular office hours, Monday through Friday, 8:00 AM to 4:30 PM. No refills on nights, holidays, or weekends. I must call at least three (3) working days ahead (M-F) to ask for a refill of my medicine. No exceptions will be made.

I must keep track of my medications. No early or emergency refills are allowed.
Pharmacy

I will use only one pharmacy to obtain my medicine. My doctor may talk with the pharmacist about my medicines.
The name of my pharmacy and store location is:
Enter the name of your pharmacy for this prescription
Prescriptions from Other Doctors

If I see another doctor who gives me a controlled substance medicine (for example, a dentist, a doctor from the emergency room or another hospital, etc.), I must bring this medicine to the clinic in the original bottle or clearly document the prescription on the bottle (via photograph), even if there are no pills remaining.
Termination of Agreement

If I break any of the above rules, or if my provider decides that this medicine is hurting me more than helping me, this medicine may be stopped by my provider in a safe manner.
By signing below, you affirm you have discussed this agreement with my provider and understand the above-stated rules. *

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Patient Agreement Form for Controlled Substance Prescriptions

Agreement for Controlled Substance Prescriptions