While on Controlled Substances Therapy, I agree to abide by the following conditions:
1.Receiving medications from a single prescriber. Provider mentioned above will be the only prescriber who will prescribe the Controlled Substances medication mentioned above for me. I will not seek to obtain Controlled Substances from any other prescriber. In case of a situation where I receive a Controlled Substances from another prescriber, I will notify my doctor as soon as possible.
2.Taking the medication as prescribed. I will take the medication at the dose and frequency ordered by my doctor. I will not increase the dose or frequency of my medication on my own. I understand that only a small supply of extra doses may be prescribed each month upon my doctor’s discretion. I agree to keep track of my use of these medications and how well they are working for me to share with my doctor at appointments, e.g. by maintaining a sleep diary.
3.NOT consuming other sedating medications or Alcohol with this medication. Use of Controlled Substances Therapy with other medications that may cause drowsiness such as opioid pain relievers (including non-prescription codeine) or with alcohol can be serious and life-threatening. Naloxone will not reverse the effects of Controlled Substances overdose. I will not combine my medication with other drugs without consulting my doctor first nor will I combine my Controlled Substances medication with alcohol.
4.NOT abruptly stopping my medication. Discontinuing Controlled Substances Therapy suddenly after extended use can cause potentially serious withdrawal symptoms. The likelihood of experiencing withdrawal can be reduced by tapering or gradually reducing the dose. I will consult with my doctor before stopping my medication to discuss a tapering plan.
5.Maintaining regular appointment attendance and participating in consultations. I understand that I need to be present at all appointments with my doctor. I must also be willing to fully participate in other treatments or consultations, such as psychotherapy, recommended by my doctor.
6.Receiving medications from a single pharmacy. I will fill my prescriptions at a single pharmacy of my choice which is mentioned above. If I decide to move to a different pharmacy, I will notify my doctor.
7.Storing and disposing of the medication safely. I will store my medications in a secure location at all times. I will not share or give my prescribed Controlled Substances medication to another person nor will I accept these medications from anyone else. If I have Controlled Substances medication remaining that I no longer need (e.g. in the case that my medication is discontinued or changed), I will take it to my pharmacy for safe disposal. I understand that I may not obtain an early refill or replacement supplies for lost medication.
8.Being responsible for medication supply and refilling on time. I will manage my medication supply by planning and booking my appointments in advance. If I run out of medication early (e.g. by missing an appointment or taking more than prescribed), extra doses may not be prescribed in which case I will have to wait until my next prescription is due. I will bring my pill bottles with any remaining pills of the medication to each appointment.
9.Complying with clinic adherence monitoring policies. I understand that my doctor may ask me for a urine drug screening sample or a count of my pills at any time. These measures are performed for all patients to improve the safety of prescribing Controlled Substances . Further refills/prescriptions will be tied to completion of requested screening.
10.Consent to share information with other health care professionals if medically necessary. I agree that my doctor has the authority to share information with other health professionals involved in my care if necessary. My pharmacy will be receiving a copy of this treatment agreement.
11.Termination of this agreement. If my doctor determines that the medication is causing me more harm than the relief it provides, my doctor has the right to discontinue my Controlled Substances medication in a safe way. I also acknowledge that I could lose my right to treatment from my doctor if I break any part of this agreement.
This document was discussed between me and my doctor. I was given the opportunity to ask questions. I affirm my understanding and acceptance of the terms of this agreement by signing this document.