As a participant in medication-assisted treatment for opioid
misuse and dependence, I freely and voluntarily agree to accept this treatment
contract as follows:
1. I agree to keep, and be on time to, all my scheduled appointments.
2. I agree to adhere to the payment policy outlined by this office.
3. I agree to conduct myself in a courteous manner with the doctor and staff.
4. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.
5. I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit will result in my not being able to get my medication/prescription until the next scheduled visit.
6. I agree to make another appointment in case of a lost prescription or stolen medication. I understand that securing my medication is my responsibility and that lost or stolen medication will likely necessitate more frequent appointments and may lead to my removal from the program.
7. I agree to store medication properly. Medication may be harmful to children, household members, guests, and pets. The Suboxone should be stored in a safe place, out of the reach of children. If anyone besides the patients ingests the medication, I agree to call the Poison Control Center (800-222-1222) or 911 immediately.
8. I agree not to obtain medications from any doctors, pharmacies, or other sources without telling my treating physician.
9. I understand that mixing this medicine with other medications, especially benzodiazepines (for example, Valium®*, Klonopin®†, or Xanax®‡), can be dangerous. I also recognize that several deaths have occurred among persons mixing buprenorphine and benzodiazepines.
10. I agree to read the Medication Guide and consult my doctor should I have any questions or experience any adverse events.
11. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.
12. I agree to notify the clinic in case of relapse to drug abuse. An appropriate treatment plan must be developed as soon as possible. The physician should be informed of relapse before random urine testing reveals it.
13. I agree with the guidelines of office operations. I understand the procedure for making appointments. I have the phone number of this clinic and I understand the office hours. I understand that no medications will be prescribed by phone or on weekends. I understand that I am required to abide by these restraints to remain on the Suboxone treatment panel of this office.
14. I agree to comply with the required med counts and urine tests. Both are a mandatory part of the program.
15. I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substances.
16. I agree to allow my doctor to test my blood alcohol level.
17. I agree to participate to random medication counts at the physician’s discretion. I understand that if I am called for a dose call back, I am obligated to present all my medication to the clinic for a count within 24 hours. I understand that failure to appear and/or having any inadequate amount of remaining medication will result in my termination from the buprenorphine program. I am encouraged to notify the office of any travel plans prior to leaving to ensure I am not called when I will not be in town.
18. I understand that violations of the above may be grounds for termination of treatment.
By signing this form, I confirm that I have fully read this contract and that I am responsible for the information in each section.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.