CONSENT TO RECEIVE CONTROLLED SUBSTANCES
Dr. Mintz has recommended that you take a medication known as a controlled substance. These medications have potential known risks that you need to understand before you agree to take them. It is important that you weigh the risks, benefits and alternatives, including not taking the medicine, in order to give your informed consent. It is also important that you understand the risks of stopping this medication abruptly without first notifying your provider.
By signing this form you are acknowledging that Dr. Mintz has explained to you that the types of medications that may be prescribed for your condition include drugs known as "controlled substances" (also known as Schedule II, III or IV drugs) and that these medications have known risks and side effects, and can be harmful if taken without medical supervision. You further understand that this medication may lead to tolerance, physical dependence and/or addiction.
In order to allow you to make an informed decision, it is important that you and Dr. Mintz discuss important aspects of these medications. By signing this form, you acknowledge that Dr. Mintz has discussed the following items and that you had an opportunity to have any of your questions answered:
1. the nature of your symptoms and your underlying medical condition.
2. the proper use of the medication that is being prescribed.
3. alternative means of treating your symptoms and the cause of your symptoms.
4. the important provisions of your treatment plan.
5. the potential risks and anticipated benefits of long-term opioid use or other medications.
6. the side effects, both short- and long-term of the medication that is being prescribed or provided, such as nausea, constipation, decreased libido, sexual dysfunction, osteoporosis, and cognitive impairment, as well as other conditions that are not listed here.
7. the fact some medications are known to have a risk of tolerance, physical dependency, and addiction over time.
8. the risk of drug interactions, over-sedation, respiratory depression, overdose, and death especially if the medication is not taken as prescribed, or combined with alcohol use or other drugs.
9. the risk of impaired motor skills affecting driving and other tasks which can lead to accidents and injury or death.
10. the serious risk of harm to an unborn child including the risks of fetal dependency on the controlled substance and neonatal abstinence syndrome, if a woman takes these medications while pregnant.
12. the methods to safely store and legally dispose of unused medication.
13. That Dr. Mintz does not prescribe any controlled substances known as opioids (Percocet, Oxycontin, codeine, oxycodone).
14. Dr. Mintz requires an in-person visit at least annually, and visits (in-person or via telehealth) every 90 days in order to prescribe and/or refill any controlled substances.
You have been told that not every possible risk and benefit can be listed on this form, and that this form only describes the most common side effects or reactions; you have also been warned about the serious dangers of overdose and/or combining the prescribed medication(s) with other drugs or alcohol, including the risk of death. .
You have been informed, and understand, that your provider may ask you to undergo medical tests and examinations before and during your treatment. Those tests may include random unannounced requests for lab work during your treatment to check for drugs, and psychological evaluations if your provider deems them necessary to assess how the medication is affecting you.
If you refuse to have those tests done, it may not be possible to assess whether the medication is causing any side effects or harming you, and it may then no longer be safe to continue prescribing the medication.