Pain Management Agreement
The purpose of this Agreement is to prevent misunderstandings about certain medicines that the patient will be taking for pain management. This is to help both patient and provider comply with the law regarding controlled medications.
This agreement relates to my use of controlled substances for chronic pain prescribed by a medical provider at the Center for Regenerative and Interventional Spine and Sports Pain (hereinafter referred to as CRISSP). I have been informed and understand the policies regarding the use of controlled substances that are followed by the staff at the CRISSP. I understand that I will be provided controlled substances while actively participating in this program only if I adhere to the following conditions:
PHARMACY
Name and Location of the Pharmacy:
Name
Location
Telephone Number
Signature
*
Are you the patient?
Yes
No
If you are signing for the patient, please answer the following:
I am permitted to sign for the patient as I am their legal guardian/medical power of attorney/decision maker.
My name is
First Name
Last Name
and my relationship to the patient is
blank
.
Patient's Name:
*
First Name
Last Name
Patient's Date of Birth (MM-DD-YYYY):
*
Submit
Should be Empty: