• CONTROLLED SUBSTANCE AGREEMENT

  • DOB:
     - -
    2 digit month, 2 digit day, 4 digit year

  • The use of   may cause addiction and is only one part of the treatment for    .

  • The goals of this medication(s):

  • I have been told that:

    1. If I drink alcohol or use street drugs, I may not be able to think clearly and I could become sleepy and risk personal injury.
    2. I may get addicted to this medicine.
    3. If I or anyone in my family has a history of drug or alcohol problems, there is a higher chance of addiction.
    4. If I need to stop this medicine, I must do it slowly or I may get very sick.
  • I agree to the following

  • Refills:

    Refills will be made only during regular office hours- Monday through Thursday, 8:00am - 5:00pm and Friday 8:00am- 2:00pm. I must call at least three (3) working days ahead (M-F) to ask for a refill of my medicine. No exceptions will be made. I must keep track of my medications. No early or emergency refills may be made.

    Privacy

    While I am taking this medicine, my doctor may need to contact other doctors or family members to get information about my care and/or use of this medicine. I will be asked to sign a release at that time.

    Termination of Agreement

    If I break any of the rules, or if my doctor decides that this medicine is hurting me more than helping me, this medicine may be stopped by my doctor in a safe way. I have talked about this agreement with my doctor, and I understand the above rules.

    Provider Responsibilities

    As your doctor, I agree to perform regular checks to see how well the medicine is working, I agree to provide primacy care for you even if you are no longer getting controlled medicines from me.

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient agrees to come in every

  • Section Below to be completed by the physician only:

     

    Physician Signature:___________________________________________ Date:_____/______/______

     

    Patient agrees to come in every (circle one:) 30 Days      60 days

     

  • Should be Empty: