Medication Responsibility Form (Controlled Substances)

This form outlines the responsibilities of the participant regarding the management of controlled substances, emphasizing safety and accountability.

II. Responsibilities of the Participant

I agree to take my medication as prescribed by my healthcare provider. I will inform my healthcare provider of any side effects or concerns about my medications.

I will store all medications, especially controlled substances, in a secure lock box I understand that it is my responsibility to ensure the lock box remains locked when not in use.

I acknowledge that I am personally responsible for my medications. This includes safeguarding against theft and loss. I understand that I must report any stolen or lost medications to Life Changes Inc. immediately and may be responsible for replacement.

I will communicate any changes in my health status or difficulties managing my medications to Life Changes Inc. staff. I will notify Life Changes Inc. staff of any issues regarding the safety or security of my medications.

I will ensure that I have an adequate supply of medication and will request refills in a timely manner. I will attend all scheduled appointments with my healthcare provider.

III. Responsibilities of Life Changes Inc.

Life Changes Inc. will provide education on the safe management of controlled substances.

Life Changes Inc. will have protocols in place for responding to medication- related emergencies. Staff will be trained to assist participants in case of adverse reactions or medication errors.

IV. Acknowledgment By signing below, I acknowledge that I have read and understood my responsibilities regarding the management of controlled substances. I agree to adhere to the guidelines set forth in this form.