• PSYCHIATRIC CONTROLLED SUBSTANCE MANAGEMENT AGREEMENT

  • This form acknowledges that the use of a Controlled Substance medication for my psychiatric care was a decision made between my provider and myself because of my specific condition. By signing this form, I acknowledge, understand and agree to the following conditions to make my treatment as safe and successful as possible. Please initial:

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  • I have read this agreement, and I fully understand the consequences of violating this agreement. My provider has answered my questions and I agree to the terms of this agreement.

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  • Should be Empty: