Sample Patient Agreement Forms (Page 4 of 5) in pdf

Patient Agreement Form

Patient Name:

Medical Record Number:

Addressograph Stamp:

AGREEMENT FOR LONG TERM CONTROLLED SUBSTANCE PRESCRIPTIONS

The use of

(print names

of medication(s)) may cause addiction and is only one part of the treatment

for:

(print name of condition—e.g., pain, anxiety, etc.).

The goals of this medicine are:

to improve my ability to work and function at home.

to help my

(print name of condition—e.g., pain, anxiety, etc.)

as much as possible without causing dangerous side effects.

I have been told that:

If I drink alcohol or use street drugs, I may not be able to think clearly and I could

become sleepy and risk personal injury.

I may get addicted to this medicine.

If I or anyone in my family has a history of drug or alcohol problems, there is a higher

chance of addiction.

If I need to stop this medicine, I must do it slowly or I may get very sick.

I agree to the following:

•

I am responsible for my medicines. I will not share, sell, or trade my medicine. I will

not take anyone else’s medicine.

•

I will not increase my medicine until I speak with my doctor or nurse.

•

My medicine may not be replaced if it is lost, stolen, or used up sooner than prescribed.

•

I will keep all appointments set up by my doctor (e.g., primary care, physical therapy, mental

health, substance abuse treatment, pain management)

•

I will bring the pill bottles with any remaining pills of this medicine to each clinic visit.

•

I agree to give a blood or urine sample, if asked, to test for drug use.

Refills

Refills will be made only during regular office hours—Monday through Friday, 8:00AM-4:30 PM.

No refills on nights, holidays, or weekends. I must call at least three (3) working days ahead

(M-F) to ask for a refill of my medicine. No exceptions will be made. I will not come to

Primary Care for my refill until I am called by the nurse.

I must keep track of my medications. No early or emergency refills may be made.

Pharmacy

I will only use one pharmacy to get my medicine. My doctor may talk with the pharmacist about

my medicines.

The name of my pharmacy is

Sample Patient Agreement Forms Page 4

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