7) Member will not obtain stimulants from other sources. If there are multiple sources of stimulants, the provider will stop prescribing the stimulant. 8) Member agrees to safe and proper storage of medication: Keep medication out of sight/reach of children. Use a locked box, bag, or cabinet for safe storage. Do not put tablets down on counters, sinks, dresser, and/or nightstands or in any public unsecure space. It is easy for children to put small pieces and crumbs in their mouth, including medications, which could result in a life-threatening situation. Poison control should be notified after removal of the medication from the child's mouth. To prevent damage to the tablet form of the medication, keeping cotton or tissue in the bottle may be indicated. Always keep medication in a labeled prescription bottle with a child-proof cap. Patient's prescribed stimulant medication should always be stored with an official pharmacy label. Patients may request a second label from the pharmacy if they plan to carry medication on their person. Avoid carrying medication in a suitcase, pocket, wallet, bag, purse, or backpack. Avoid leaving the medication in the bathroom, car, or any public space. Call 911 if an accidental exposure occurs and/or go to the nearest emergency department.
9) Provider may choose to stop prescribing the stimulant if the member fails to follow the provider's advice, is having/at high risk for major side effects, fails to keep appointments, or if it is determined that the stimulant is no longer safe, helpful, or necessary.
PLEASE NOTE THAT THIS AGREEMENT WILL REMAIN IN EFFECT IF YOU TRANSFER TO A DIFFERENT PROVIDER IN THIS CLINIC.
I agree and understand all the above and provide my consent.