Sample Patient Agreement Forms (Page 3 of 5) in pdf

I will not use illegal drugs such as heroin, cocaine, marijuana, or amphetamines. I

understand that if I do, my treatment may be stopped.

I will come in for drug testing and counting of my pills within 24 hours of being called. I

understand that I must make sure the office has current contact information in order to reach me, and

that any missed tests will be considered positive for drugs.

I will keep up to date with any bills from the office and tell the doctor or member of the

treatment team immediately if I lose my insurance or can't pay for treatment anymore.

I understand that I may lose my right to treatment in this office if I break any part of this

agreement.

Pain Treatment Program Statement

We here at

are making a commitment to work with you in your efforts to

get better. To help you in this work, we agree that:

We will help you schedule regular appointments for medicine refills. If we have to cancel or

change your appointment for any reason, we will make sure you have enough medication to last

until your next appointment.

We will make sure that this treatment is as safe as possible. We will check regularly to make

sure you are not having bad side effects.

We will keep track of your prescriptions and test for drug use regularly to help you feel like you are

being monitored well.

We will help connect you with other forms of treatment to help you with your condition. We

will help set treatment goals and monitor your progress in achieving those goals.

We will work with any other doctors or providers you are seeing so that they can treat you safely and

effectively.

We will work with your medical insurance providers to make sure you do not go without medicine

because of paperwork or other things they may ask for.

If you become addicted to these medications, we will help you get treatment and get off of the

medications that are causing you problems safely, without getting sick.

Patient signature

Patient name printed

Date

Provider signature

Provider name printed

Date

*Adapted from the American Academy of Pain Medicine

Sample Patient Agreement Forms Page 3