The goal of this medicine are:
-to help improve my ability to work and function at home
-to help the aforementioned condition(s) as much as possible without causing dangerous side effects.
I have been counseled that:
1. If I drink alcohol or use street drugs, I may not be able to think clearly and could
become sleepy and risk personal injury and death.
2. I may get addicted to this medication.
3. If I or anyone in my family has a history of drug or alcohol problems, there is a higher chance of addiction.
4. If I need to stop this medication, I must do it slowly or I may get very sick.
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 understand doing so is a felony crime.
- I will not increase my medicine until I speak with the provider and they agree. I will
only take the medicine as written.
- My medicine may not be replaced if it is lost, stolen or used up sooner than
prescribed.
-I will keep all appointments recommended to me by my provider, including seeing a
counselor or therapist.
-I agree to give a blood or urine sample, if requested, to test for drug use.
-I agree that if I get a DUI or drug charge I will call the provider and make them aware within 24 hours of the occurrence.
Refill Policy:
Refills will be made only during regular office hours accompanied by an evaluation with the provider. No refills will be granted at night, holidays or on the weekends. No exceptions will be made. I will keep track of my medications. No early or emergency refills may be made.
Prescriptions from Other Doctors:
If I see another provider who gives me a controlled substance medicine (for example a dentist or doctor from the Emergency Department) I must call Dawson Integrative Medical Center, LLC to let the provider know of the change to my medications within 24 hours of the change.
Termination of Agreement:
If I break any of the rules, or if my provider decides that this medicine is hurting me more than helping me the medication may be stopped by the provider in a safe way. If I am charged with a drug crime or a DUI my medication may be stopped/tapered off at that time. I have talked about this with the provider and I understand the above rules.
Provider Responsibilities:
As your provider I agree to perform regular checks to see how well the medication is working.