As a participant in medication-assisted treatment for opioid
misuse and dependence, I freely and voluntarily agree to accept this treatment
contract as follows:
1. I agree to keep, and be on time to,
all my scheduled appointments.
2. I agree to adhere to the payment
policy outlined by this office.
3. I agree to conduct myself in a
courteous manner in the doctor’s office.
4. I agree not to sell, share, or give
any of my medication to another person.
I understand that such mishandling of my medication is a serious
violation of this agreement and would result in my treatment being terminated
without any recourse for appeal.
5. I agree not to deal, steal, or
conduct any illegal or disruptive activities in the doctor’s office.
6. I understand that if dealing or
stealing or if any illegal or disruptive activities are observed or suspected
by employees of the pharmacy where my medication is filled, that the behavior
will be reported to my doctor’s office and could result in my treatment being
terminated without any recourse for appeal.
7. I agree that my medication/prescription can only be given to me at
my regular office visits. A missed visit will result
in my not being able to get my medication/prescription until the next scheduled
8. I agree to make another appointment
in case of a lost prescription or stolen medication. I understand that securing my medication is my responsibility
and that lost or stolen medication will likely necessitate more frequent
appointments and may lead to my removal from the program.
9. I agree to store medication
properly. Medication may be harmful to
children, household members, guests, and pets.
The Suboxone should be stored in a safe place, out of the reach of
children. If anyone besides the patients
ingests the medication, I agree to call the Poison Control Center
(800-222-1222) or 911 immediately.
10. Iagree not to obtain medications from any doctors, pharmacies, or other sources
without telling my treating physician.
11. I understand that mixing this medicine with other medications, especially
benzodiazepines (for example, Valium®*, Klonopin®†, or
Xanax®‡), can be dangerous. I
also recognize that several deaths have occurred among persons mixing
buprenorphine and benzodiazepines.
12. I agree to read the Medication Guide and consult my doctor should I have any
questions or experience any adverse events.
13. I agree to take my medication as my doctor has instructed and not to alter the
way I take my medication without first consulting my doctor.
14. I understand that medication alone is not sufficient treatment for my condition,
and I agree to participate in counseling as discussed and agreed upon with my
doctor and specified in my treatment plan.
15. I agree to notify the clinic in case of a relapse to drug abuse. An appropriate treatment plan must be
developed as soon as possible. The
physician should be informed of a relapse before random urine testing reveals
16. I agree to the guidelines of office operations.
I understand the procedure for making appointments. I have the phone
number of this clinic and I understand the office hours. I understand that no
medications will be prescribed by phone or on weekends. I understand that I am required to abide by
these restraints in order to remain on the Suboxone treatment panel of this
17. I agree to comply with the required med counts and urine tests. Urine testing is a mandatory part of office
maintenance. The patient must be
prepared to give a urine sample for testing at each clinic visit and to show Suboxone
for a count including reserve medication.
18. I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive
19. I agree to allow my doctor to test my blood alcohol level.
20.I agree to participate to random medication counts at the physicians discretion.
I understand that if I am called for a dose call back I am obligated to present
all of my medication to the clinic for a count within 24 hours. I understand that failure to appear and/or
having any inadequate amount of remaining medication will result in my
termination from the buprenorphine program.
I am encouraged to notify the office of any travel plans prior to
leaving to ensure I am not called when I will not be in town.
21. I understand that violations of the above may be grounds for termination of
By signing this form, I confirm that I have fully read this contract and that I am responsible for the information in each section.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.