Stimulant Agreement - Oklahoma Primary Associates

Stimulant Agreement

PROVIDER-PATIENT AGREEMENT FOR STIMULANT MEDICATIONS
Patient Name

First NameLast Name
I understand that I have Attention-Deficit/Hyperactivity Disorder (ADHD) that currently requires the use of controlled medication to increase my function. Stimulant medications can be a safe and effective way of treating patients with ADHD. These medications are classified as Schedule II controlled substances by the United States Drug Enforcement Agency (DEA). This means that there are strict federal laws regarding these prescription medications.

I understand that compliance with the following guidelines is imperative in continuing ADHD treatment with Oklahoma Primary Associates. I understand that I have the following responsibilities and agree to adhere to all the following rules while I am under the care of Oklahoma Primary Associates:
I will obtain controlled substances from only the physician whose signature appears below or, during his or her extended absence, from the covering physician.I will schedule a visit with my physician every 90 days or less for continued care and medication refills. Refills will not be authorized when the clinic is closed, after hours, or on weekends.The prescribing physician has permission to discuss all diagnostic and treatment details with dispensing pharmacists or other professionals who provide my health care for the purpose of maintaining accountability.I agree to take my medication only as directed.I will not increase, decrease, or abruptly stop taking my medication without my physician’s knowledge and permission.I will not request early refills.Medications may not be replaced if lost, destroyed/damaged, or stolen. I understand that it is my responsibility to secure my medication properly.I understand it is my responsibility to schedule a more urgent appointment if I begin to experience any problems associated with my controlled medications, or if other medical conditions occur which may affect my medication.I am aware of the risks of concurrent alcohol, marijuana, and illegal substance use. I will not use marijuana or illegal substances while taking my controlled medication and understand doing so may result in discontinuation of controlled medication prescriptions.I agree to yearly and periodic random drug screening tests.I will not sell or share my controlled medications, allow others to use my medication, alter my medication prescriptions, or use my medications in any unintended ways. I will keep my medications safe and secure.I will notify my provider if I intend on becoming pregnant or become pregnant.I understand my provider may choose to discontinue my controlled medication if he/she believes that my ADHD is not improving, my medication usage is escalating, my functional ability is not increasing, if I begin to experience unacceptable side effects, or if deemed necessary.
Notice of Risk

The use of stimulant medications may be associated with certain risk such as, but not limited to:

Central nervous system: jitteriness, sleep disturbance, tension, psychomotor restlessness, and emotional lability.

Cardiovascular: blood pressure elevation, tachycardia, arrhythmia, palpitations.

Gastrointestinal: weight loss, poor growth, anorexia.

Dermatological: itching and rash.

Endocrine and metabolic: hot flashes, increased thirst, weight loss.

Urinary: erectile dysfunction.

Drug Interactions with or altering the effect of other medications cannot be reliably predicted.

Addiction (abuse): This refers to abnormal behavior directed towards acquiring or using drugs in a nonmedically supervised manner. Patients with a history of alcohol and/or drug abuse are at increased risk for developing addiction.

Physical dependence: Physical dependence means that I will experience withdrawal symptoms if my medication use is markedly decreased, discontinued, or reversed by other drugs. Withdrawal from stimulants includes extreme fatigue, mental depression, and changes in sleep.

Allergic reactions are possible with any medication. This usually occurs early after initiation of the medication. Most side effects are transient and can be controlled by continued therapy or the use of other medications.

The risks, side effects and benefits of the medication have been discussed with me in detail. I understand the risks and benefits of taking this stimulant and agree to the terms above. I understand violation of this agreement may terminate any further treatment of my condition with controlled stimulant medications.
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