Sample Patient Agreement Forms

Sample Patient

Agreement Forms

Introduction

This resource includes two sample patient agreement forms that can

be used with patients who are beginning long-term treatment with

opioid analgesics or other controlled substances. These documents

contain statements to help ensure patients understand their role and

responsibilities regarding their treatment (e.g., how to obtain refills,

conditions of medication use), the conditions under which their treatment

may be terminated, and the responsibilities of the health care provider.

These documents can help facilitate communication between patients and

healthcare providers and resolve any questions or concerns before initiation

of long-term treatment with a controlled substance.

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