The use of __{substance}__ may cause addiction and is only one part of the treatment for: __{illness}__

 

The goals of this medicine are:

1. To improve my ability to work and function at home.
2. To help my __{illness}__ 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 get 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 addiction.
4. If I need to stop this medicine, I must do it slowly or I may get very sick.

 

I agree to the following:

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.

My medicine may not be replaced if it is lost, stolen, or used up sooner than prescribed. If any of the above situations happen I agree to follow my doctor’s recommendation which might include filing a police report and being tested for illegal drug use. I agree to make a new appointment and see my doctor for a case by case assessment. 

I will keep all appointments recommended by my doctor (e.g., primary care, physical therapy, mental health, substance abuse treatment, pain management)

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 am aware the out of pocket cost is 30$.

 

Refills

Refills will be made only during a regular visit with my psychiatrist. No refills will be given over the phone, No exceptions will be made. I will not go to Primary Care for my refill. I must keep track of my medications. No early or emergency refills may be made.

 

Pharmacy

I will only use one pharmacy to get my medicine. My doctor may talk with the pharmacist about my medicines. The name of my pharmacy is __{pharmacy}__ .

 

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 my psychiatrist in the original bottle, even if there are no pills left.

 

Privacy 

While I am taking this medicine, my doctor may need to contact other doctors or family members to get information about my care and/or use of this medicine. I will be asked to sign a release at that time.

 

Termination of Agreement

If I break any of the rules, or if my doctor decides that this medicine is hurting me more than helping me, this medicine may be stopped by my doctor in a safe way. 

I have talked about this agreement with my doctor and I understand the above rules.

 

Provider Responsibilities

As your doctor, I agree to perform regular checks to see how well the medicine is working.