As a participant in mental health/pain treatment, 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 in the doctor’s office.
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.
I agree not to deal, steal, or conduct any illegal or disrupted activities in the doctor’s office.
6.I understand that if dealing, stealing, or any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medication is filled, that the behavior will be reported to my doctor’s office and could result in my treatment being terminated without recourse for appeal.
7.I agree that the medication/prescription can only be given to me at my regular office visit. A missed visit may result in my being unable to get my medication/prescription until my next scheduled visit.
8.I agree that the medication I received is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of why it was lost.
9.I agree not to obtain medications from any other doctors, pharmacies, or other sources without telling my treating physician.
10.I understand that mixing medications, especially benzodiazepines (for example, Valium, Klonopin, or Xanax), can be dangerous. I also recognize that several deaths have occurred among persons mixing medications and benzodiazepine. (especially if taken outside the care of a physician, using routs of administration other than oral or in higher than recommended therapeutic doses
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 understand the medication alone is not sufficient treatment for my condition, and I agree to participate in additional recommended treatment as discussed and agreed upon with my doctor and specified in my treatment plan.
13.I agree to abstain from cocaine, opioids, and other addictive substances (excepting nicotine
14.I agree to provide random urine or saliva samples and have my doctor test my blood alcohol level and random pill counts per the doctor’s discretion.
15.I understand that violations of the above may be grounds for termination of treatment.