The State of Florida has laws governing the prescription of controlled substances. These drugs include, but are not limited to, all opioids (such as codeine, hydrocodone, oxycodone, buprenorphine, etc.), sleeping aids (such as Ambien, Lunesta, etc.), all benzodiazepines (such as Valium, Xanax, Klonopin, Ativan, etc.) and ADHD medications (such as Adderall, Vyvanse, etc.)
I will check your prescription history before every visit via a statewide program called E-Force (PDMP). You can request a copy of the report if you want to see it yourself.
I acknowledge and agree to the following:
Prescriptions for controlled substance medications can only be written for a 30-day supply.
I will not share, sell, or trade my medication with anyone.
I will safeguard my medicine from loss or theft. I understand that any "lost or stolen prescriptions" will not be replaced. NO EXCEPTIONS.
I will use my medicine at a rate no greater than the prescribed. Using my prescription at a greater rate could result in my being without medication for some time.
I will request refills of my controlled substance only during a therapeutic visit. No refills will be available during evenings, weekends, or outside the scheduled visits.
I will submit to a blood or urine test within 24 hours if/when my doctor requests to determine my compliance.
I will communicate fully and truthfully with my doctor about my medical condition.
I will obtain all controlled medicines only from Dr. Nielsen. If another doctor prescribes a controlled substance medicine (for example, a dentist or a doctor from the Emergency Room), I notify Dr. Nielsen immediately in writing.
I acknowledge that controlled substance medications have inherent risks associated with their use. These risks include but are not limited to physical dependence, psychological dependence, the potential for overdose, and the potential for withdrawal syndrome.
I understand that my physician has the right to discontinue prescribing controlled substance medications and discharge me from care if I do not comply with the terms of this agreement.
I hold Dr. Sue Nielsen and Welcome Om Life, LLC harmless from any liability if I am dismissed from the practice for failing to abide by this agreement.
I hold Dr. Sue Nielsen and Welcome Om Life, LLC harmless from any liabiliCONTROLLED SUBSTANCE AGREEMENT
The State of Florida has laws governing the prescription of controlled substances. These drugs include, but are not limited to, all opioids (such as codeine, hydrocodone, oxycodone, buprenorphine, etc.), sleeping aids (such as Ambien, Lunesta, etc.), all benzodiazepines (such as Valium, Xanax, Klonopin, Ativan, etc.) and ADHD medications (such as Adderall, Vyvanse, etc.)
I will check your prescription history before every visit via a statewide program called E-Force (PDMP). You can request a copy of the report if you want to see it yourself.
I acknowledge and agree to the following:
1. Prescriptions for controlled substance medications can only be written for a 30-day supply.
2. I will not share, sell, or trade my medication with anyone.
3. I will safeguard my medicine from loss or theft. I understand that any "lost or stolen prescriptions" will not be replaced. NO EXCEPTIONS.
4. I will use my medicine at a rate no greater than the prescribed. Using my prescription at a greater rate could result in my being without medication for some time.
5.I will request refills of my controlled substance only during a therapeutic visit. No refills will be available during evenings, weekends, or outside the scheduled visits.
I will submit to a blood or urine test within 24 hours if/when my doctor requests to determine my compliance.
6. I will communicate fully and truthfully with my doctor about my medical condition.
7. I will obtain all controlled medicines only from Dr. Nielsen. If another doctor prescribes a controlled substance medicine (for example, a dentist or a doctor from the Emergency Room), I notify Dr. Nielsen immediately in writing.
8. I acknowledge that controlled substance medications have inherent risks associated with their use. These risks include but are not limited to physical dependence, psychological dependence, the potential for overdose, and the potential for withdrawal syndrome.
9. I understand that my physician has the right to discontinue prescribing controlled substance medications and discharge me from care if I do not comply with the terms of this agreement.
10. I hold Dr. Sue Nielsen and Welcome Om Life, LLC harmless from any liability if I am dismissed from the practice for failing to abide by this agreement.
11. I hold Dr. Sue Nielsen and Welcome Om Life, LLC harmless from any liability for my misuse of my medications.
12. I will only use the pharmacy that Dr. Nielsen and I have agreed upon for prescriptions.
My signature below indicates I have read this agreement, understand the content, and will abide by the provisions.