Controlled Substance Agreement
Controlled substance medications can be useful, but have potential for misuse. They are controlled by the local, state and federal government. They are intended to improve function and/or ability to work and the decision to use these medications was made between my provider and myself because of my specific condition. When I sign this form I acknowledge that I understand and agree to the following conditions to make my treatment as safe and successful as possible.
1. I am aware that the use of such medicine has certain risks associated with it, and I have reviewed these risks with my provider. I have been fully informed by my provider regarding the potential risk of psychological dependence on a controlled substance. I know that some persons may develop a tolerance, which is the need to increase the dose of the medication to achieve the desired effect. I know that I may become physically dependent on the medication. This will occur if I am on the medication for several weeks; when I stop the medication I must do so slowly and under medical supervision or I may have withdrawal symptoms (which can include seizures on benzodiazepines).
2. Because of the risk for serious withdrawal symptoms and/or interactions with other medications, I understand that I should wear a medical alert bracelet/device listing the medication I am taking.
3. I have informed my provider of any past history of substance abuse or misuse. This includes inpatient or outpatient chemical dependency treatment.
4. I agree to tell my doctor about all other medicines and treatments that I am receiving. I will not request or accept controlled substances/medications from any other physician or individual without talking about it with my provider while I am receiving controlled medication from a Psych Atlanta provider. To do so may endanger my health and our provider-client relationship . The only exception is medication prescribed while I am admitted to a hospital.
5. I am responsible for my controlled substance medications. I agree to take my medication as prescribed. I understand the following refill policy will apply:
Medications will not be refilled early, even if they have been lost, stolen or destroyed.
Medications will not be refilled on weekends or holidays.
Medications will not be refilled if I run out of it early.
6. I agree to keep all scheduled appointment s. I understand that if I miss an appointment, my prescription may not be refilled until my appointment.
7. I agree to submit to urinalysis screenings as needed as determined by my provider.
8. I agree to avoid alcohol and "street drugs" while using these medications.
9. I agree to keep my medications in a locked, safe location, out of reach from children and anyone who may be a risk to take my medications.
10. I understand that if I fail to comply with the guidelines in this agreement and on my prescription labels; if I obtain controlled substances elsewhere (even from a physician); if I use illicit drugs; if I share controlled substances with others; or if I alter a prescription, our doctor-client relationship may be terminated .
I have read this agreement. I fully understand the consequences of violating this agreement.
My provider has answered my questions and I agree to the terms of the agreement.