I agree to the following:
I am responsible for my medicines. I will not share, sell, or trade my medicine. I will not take anyone else’s medicine.
I will not combine alcohol or any narcotic pain medicine with ADHD medicine or anxiety medicine.
When possible, I will check my blood pressure or have it checked prior to each telemedicine visit and report the result to my provider at the time of the visit.
I will not adjust the dose of my medicine without discussing it with my provider.
My medicine may not be replaced if it is lost, stolen, or used up sooner than prescribed. I will make every attempt to keep all appointments and understand receiving controlled substance medicine requires face to face visits at least every 90 days.
I agree to gradually taper controlled substance anxiety medicines or attend regular therapy appointments, if the medicine will be continued long-term.
I agree to give a blood or urine sample, if asked, to test for the medicine that is being prescribed to me.
Random Drug Screens and Pill Counts
I understand that I may be called in to do both random and scheduled drug screening and pill count upon request of my provider or counselor if he/she deems necessary. I understand I will have 36 hours to comply to this request.
Refills
Refills and dose adjustments for my ADHD medicine will only be made during my provider visits. Refills will only be made during regular business hours for my anxiety medicine or during my provider visits. No refills on nights, holidays, or weekends. No exceptions will be made.
I must keep track of my medications. No early or emergency refills will be made.
Pharmacy
I will only use one pharmacy to get my medicine. If I decide to change pharmacies, I will notify my provider. My provider may talk with the pharmacist about my medicines.
Prescriptions from Other Providers
If I see another provider who gives me a controlled substance medicine (for example, a dentist, a doctor from the Emergency Room, my primary care provider, etc.) I must notify my provider.
Privacy
While I am taking this medicine, I give my provider permission to contact other doctors to get information about my care and/or use of this medicine, if needed.
Termination of Agreement
If I break any of the above terms of the agreement, or if my provider decides that this medicine is hurting me more than helping me, this medicine may be stopped by my provider in a safe way.
I have read this agreement and understand the terms above.
Provider Responsibilities
As your provider, I agree to perform regular checks to see how well the medicine is working.
I agree to provide care for you even if you are no longer receiving controlled substance medicines from me.