• I understand that the buprenorphine medication is strictly for my own use. I will never give my buprenorphine medication to others. Giving or selling such medicines is a criminal act. Changing or forging a prescription is also a crime (felony).
• I will let you know about any medications prescribed for me by any other health care providers, and inform any other health care providers of my treatment contract with you.
• I will take my medication as prescribed. I will not take my medication in any way that is not authorized by you (or other physicians in your office), including stopping it, increasing the dose above the range on the bottle, or sharing it.
• I understand that mixing buprenorphine with alcohol and other medications, especially benzodiazepines (for example, Valium, Klonopin, or Xanax), can be dangerous. I also recognize that several deaths have occurred among persons mixing buprenorphine and benzodiazepines (especially if taken outside the care of a physician, using routes of administration other than sublingual or in higher than recommended therapeutic doses).
• I agree not to self-medicate or take any street drugs or recreational drugs during the course of treatment.
• I agree to inform you of any over-the-counter drugs, vitamin supplements, and herbal remedies I am taking.
• I give consent for urine screening (drug testing) at your discretion, at any time during treatment, and will be prepared to provide a urine sample any time I am in your office. I also agree to bring my medication in to the office for a pill count when requested.
• I will not drive or operate motorized equipment after beginning buprenorphine or after a change (such as a dose increase) until I have assessed the effects of the medication. I will not drive or operate motorized equipment if I ever feel sedated or mentally impaired.
• I understand that you will prescribe enough medication to last until my next visit or next scheduled medication refill date, and that you will not provide additional refills before that.
• I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed and agreed upon with you and specified in my treatment plan.
• I understand that refills for medications are not given on an emergency basis, after hours, on weekends, or on holidays.
• I understand that prescriptions are like money, and that if I lose my medication or the written prescription, it may not be replaced. I agree to contact your office in the event that I have lost my medication or prescription, and that I may have to wait until my next visit or scheduled refill date.
• I am aware that prescription medications are potentially dangerous when not monitored by a physician, and are frequently the target of theft for illegal use. I will be responsible for making sure that my medications are hidden or secured. I will consider using a safe or some other mechanism to lock up my medications.
• I understand this medication is especially dangerous if ingested by a child. I agree to take precautions to keep this medication out of the reach of children.
• I understand that I am required to schedule and keep all follow-up appointments as requested by you or call at least 24 hours in advance to reschedule my appointment.
• I understand that prescriptions for buprenorphine will not be mailed. I will pick up my refill prescription at the office every month or as directed by you.
• If it appears to you that buprenorphine is no longer medically indicated, it may be discontinued. I will gradually taper my medication as prescribed by you.

By signing below, I agree that I have read and understand the conditions above. If I am not able to honor the commitments made in this agreement, I will notify you. I understand that failure to follow this agreement may lead to termination of this contract and, potentially, my care with you. If this occurs, I understand that I will be notified in person or at my last known address.

Also by signing below, I am giving your office permission to share this agreement with other health care providers and pharmacies for coordination of care.

I authorize the release of any information, including this agreement and hospital records, by my physician or his/her designate to other healthcare providers, pharmacies, my insurance company, other reimbursing agencies, law enforcement, and other authorities as required by state and/or federal law. I also authorize any pharmacy to release information regarding my prescriptions.