• Stark Medical Chronic Stimulant Treatment Agreement

    • I agree to use stimulant drugs as part of my medical treatment.
    • I am responsible for my medications. I agree to take the medication only as prescribed.
    • I understand that increasing my dose without the close supervision of my physician can lead to potentially serious increased side effects.
    • I understand that stopping this medication suddenly if I have been on it for a long time can occasionally lead to withdrawal symptoms.
    • I will not request or accept any stimulant medication from a physician or individual other than Neil Stark, DO so long as I am under his/her care. I understand that I will be immediately discharged from this practice, if it is determined that I accepted stimulant medications from other health care providers or individuals.
    • I understand that side effects may occur with stimulant medications. The most common side effects are headache, stomach aches, difficulty sleeping and appetite decrease. For women: I agree to notify my physician if I become pregnant, as this class of drugs may harm the developing baby.
    • I understand that the stimulant medication is strictly for my own use. I will never give the stimulant medication to others. Giving or selling such medicines is a criminal act. Changing or forging a prescription is also a crime (felony).
    • During the time that my stimulant medication dose is being adjusted, I will return for follow-up office visits whenever instructed by my prescriber. After I have been placed on a stable dose, I will return to the office for a medical evaluation at least once every 6 months. I will not increase the dose unless I discuss it first with my physician.
    • If it appears to my physician that there is no improvement to my daily function or quality of life from the controlled substance, my stimulant medication may be discontinued. I will taper my medication as prescribed by my physician.
    • I agree to submit to urine and blood screens at any time as determined by my physician to detect the use of both prescribed and non-prescribed medications. If non- prescribed or street drugs are detected, or my medicine is not detected when it should be, I will not be prescribed further stimulant medicine.
    • I authorize the release of any information and hospital records by my physician or his/her designate to other healthcare providers, my family, my employer, my insurance company, law enforcement, and other reimbursing agencies. I also authorize any pharmacy to release information regarding my prescriptions.
    • I understand that if I do not follow all of the above conditions, my physician may determine that stimulant therapy is no longer appropriate for my care. I will then be taken off this medication and other therapies will be used or I may be discharged from the office.

  • I am responsible for my stimulant prescriptions. I understand that prescription refills:

    • Must be filled at the same pharmacy. PHARMACY: *
    • Will not be given if I “run out early” or “lose a prescription” or “spill or misplace my medication.”
    • I am responsible for taking the medication in the dose prescribed and for keeping track of the amount remaining. If my medication is stolen, I will report this to my local police department and obtain a stolen item report. Replacement prescriptions will be given at the discretion of my physician, and likely will not be replaced.

  • ** In addition to myself, I authorize the following people to pick up my stimulant prescription. I understand that they will be required to present identification and I am responsible for informing them of this. * *

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • FOR OFFICE USE ONLY

    Provider Signature:        
    Provider Name:          
    Date:      

  • Should be Empty: