Patient Consent, Pledge, and Acknowledgment for Controlled Substances Prescription

I am receiving this Patient Prescription Consent, Pledge, and Acknowledgment because my provider at Riverview Psychiatric Medicine PC d/b/a Clearwave Psychiatry ("Clearwave") intends to prescribe me a controlled substance (e.g. benzodiazepines/stimulants/hypnotics By signing below, I acknowledge that I understand the following risk factors and that I will agree to follow the terms as set forth below:

1. I permit Clearwave to review the complete pharmacy database of prescriptions filled in my name.

2. I have discussed the risks and benefits of the prescribed medication with my provider and understand these risks and benefits and have been given the opportunity to ask questions.

3. I understand that the risks involved in taking the prescribed medication are increased by taking the medication in a manner other than the way in which my provider prescribed and by taking the medication with other drugs or alcohol.

4. I hereby pledge not to exceed the prescribed dose of the medication. I understand that, if I do, it would be considered grounds for dismissal from Clearwave, and no early refills will be supplied.

5. I hereby pledge to store my medication securely. I pledge to ensure that no one else takes my medication, and I will not give my medication to anyone else.

6. I understand that my provider and Clearwave reserve their right to deny refill requests for lost, stolen, or wasted medications.

7. I agree to have random urine drug screen tests done within 24 hours when ordered by my provider.

8. I agree to report to Clearwave all medications prescribed by other providers, and not to obtain similar medications (benzodiazepines/stimulants) from other providers.

9. I agree with the treatment plan set forth by my provider, and I understand that I will need to schedule future appointments to maintain a supply of medication. Depending on the recommendation of my Clearwave provider, this may involve regular recurrent appointments. I understand that failure to attend appointments may lead to a denial of a refill request.

10. I understand that a violation of anything set forth above may lead to discontinuation of the controlled substance and may lead to the discontinuation of treatment altogether. This decision will be at the sole discretion of my provider and Clearwave.