• Stark Medical Controlled Substances Treatment Agreement

    Controlled Substances can be dangerous. If they are not used carefully, you can become addicted to them or overdose on them. An overdose can cause death. Because of these dangers, it is important for you to understand the rules for using these medicines. This document describes our policy for prescribing these medicines and what your role is to keep yourself safe and get the best results if you use controlled substances.
    • The risks, side effects, and benefits of my controlled substance medicines have been explained to me.
    • I understand that if my activity level or general function get worse, my medicine will be changed or stopped.
    • I understand medicines are only part of an effective treatment plan for me. I will also participate in other treatments recommended, such as behavioral health and physical therapy.
    • I will take my controlled substance medicines only the way they have been prescribed. I will not change how I take these medicines without first talking to my doctor or health care team.
    • I will keep my controlled substance medicines in a safe place AND away from children.
    • I will tell other doctors and consultants I see that I am taking controlled substance medicines
    • If I get controlled substances from another doctor for other reasons, I will tell my health care team in this office.
    • I will make follow-up appointments as directed and will not miss appointments. I understand that prescription refills cannot be handled over the phone.
    • I will not ask for extra or early refills if I run out early for any reason, or if my controlled substance medicines
      are lost or stolen.
    • I will not abuse (drink too much) alcohol, use illegal drugs (cocaine, heroin, methamphetamines) or use any
      controlled substances my provider did not prescribe for me.
    • I will not share, sell, or trade my controlled substance medicines with anyone.
    • I will allow my urine or blood to be checked to see what drugs I am taking at any time.
    • I agree to bring my medicines to this office if asked to.
    • I understand that if there is reason to believe I have engaged in illegal activity, my doctor or team may notify the proper authorities.
    • I agree that other health care offices or pharmacists involved in my care may be contacted to discuss my progress and share information about this agreement.
    • I will get my controlled substance medicines only from STARK MEDICAL and at*
    • In addition to myself, I authorize the following people to pick up my narcotic prescription. I understand that they will be required to present identification and I am responsible for informing them of this.
    1. *
    2. *
  • Date*
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    2 digit month, 2 digit day, 4 digit year

  • FOR OFFICE USE ONLY

    Provider Signature:        
    Provider Name:          
    Date:      

  • Should be Empty: