Sample Patient Agreement Forms (Page 2 of 5) in pdf

Pain Treatment with Opioid Medications: Patient Agreement*

, understand and voluntarily agree that

(initial each statement after reviewing):

I will keep (and be on time for) all my scheduled appointments with the doctor and other

members of the treatment team.

I will participate in all other types of treatment that I am asked to participate in.

I will keep the medicine safe, secure and out of the reach of children. If the medicine is

lost or stolen, I understand it will not be replaced until my next appointment, and may not be

replaced at all.

I will take my medication as instructed and not change the way I take it without first

talking to the doctor or other member of the treatment team.

I will not call between appointments, or at night or on the weekends looking for refills. I

understand that prescriptions will be filled only during scheduled office visits with the treatment

team.

I will make sure I have an appointment for refills. If I am having trouble making an

appointment, I will tell a member of the treatment team immediately.

I will treat the staff at the office respectfully at all times. I understand that if I am

disrespectful to staff or disrupt the care of other patients my treatment will be stopped.

I will not sell this medicine or share it with others. I understand that if I do, my treatment

will be stopped.

I will sign a release form to let the doctor speak to all other doctors or providers that I

see.

I will tell the doctor all other medicines that I take, and let him/her know right away if I

have a prescription for a new medicine.

I will use only one pharmacy to get all on my medicines:

Pharmacy name/phone#

I will not get any opioid pain medicines or other medicines that can be addictive such as

benzodiazepines (klonopin, xanax, valium) or stimulants (ritalin, amphetamine) without telling a

member of the treatment team before I fill that prescription. I understand that the only exception

to this is if I need pain medicine for an emergency at night or on the weekends.

*Adapted from the American Academy of Pain Medicine

Sample Patient Agreement Forms Page 2