Sample Patient Contract Template printable pdf download

Sample Patient Contract

for

Using Opioid Pain Medication in Chronic Pam

This is an agreement between ___________________________________ (the patient) and

Dr._________________________________ (the doctor) concerning the Use opioid analgesics

(narcotic pain-killers) for the treatment of chronic pain problem. The medication will probably

not completely eliminate my pain, but is expected to reduce it enough that I may become more

functional and improve my quality of life.

I understand that opioid analgesics are strong medications for pain relief and I. have been

informed of the risks and side effects involved with taking them.

In particular, I understand that opioid analgesics could cause physical dependence. If I

suddenly stop or decrease the medication, I could have withdrawal symptoms (flu-like syndrome

such as nausea, vomiting diarrhea, aches, sweating, chills) that may occur within 24-48 hours of

the last dose. I understand that opioid withdrawal is quite uncomfortable but not a life-

threatening condition.

I understand that if I am pregnant or become pregnant while taking these opioid

medications, my child would be physically dependent on the opioids, and withdrawal can be life-

threatening for a baby.

Overdose on this medication may cause death by stopping my breathing; this can be

reversed by emergency medical personnel if they know I have taken narcotic pain-killers. It is

suggested that I wear a medical alert bracelet or necklace that contains this information.

If the medication causes drowsiness, sedation, or dizziness, I understand that I must not

drive a motor vehicle or operate machinery that could put my life or someone else’s life in

jeopardy.

I understand it is my responsibility to inform the doctor of any and all side effects I have

from this medication.

I agree to take this medication as prescribed, and not to change the amount or frequency

of the medication without discussing it with the prescribing doctor. Running out early, needing

early refills, escalating doses without permission, and losing prescriptions may be signs of

misuse of the medication, and may be reasons for the doctor to discontinue prescribing to me.

I agree that the opioids will be prescribed by only one doctor, and I agree to fill my

prescriptions at only one pharmacy. I agree not to take any pain medication or mind altering

medication prescribed by any other physician without first discussing it with the above named

doctor. I give permission for the doctor to verify that I am not seeing other doctors for opioid

medication or going to other pharmacies.

I agree to keep my medication in a safe and secure place. Lost, stolen, or damaged

Sample Patient Contract Template