• Patient Agreement Form for Controlled Substance Prescriptions

    Please fill in the form below
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  • Agreement for Controlled Substance Prescriptions

  • The use of * (print names of medication(s)) may cause addiction and is only one part of the treatment for * (print the name of condition - e.g. pain, anxiety, etc.).

  • 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.

  • 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.

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