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

Sample Patient Agreement Forms Page 5

Prescriptions from Other Doctors

If I see another doctor who gives me a controlled substance medicine (for example, a

dentist, a doctor from the Emergency Room or another hospital, etc.) I must bring this

medicine to Primary Care in the original bottle, even if there are no pills left.

Privacy

While I am taking this medicine, my doctor may need to contact other doctors or family

members to get information about my care and/or use of this medicine. I will be asked to

sign a release at that time.

Termination of Agreement

If I break any of the rules, or if my doctor decides that this medicine is hurting me more than

helping me, this medicine may be stopped by my doctor in a safe way.

I have talked about this agreement with my doctor and I understand the above rules.

Provider Responsibilities

As your doctor, I agree to perform regular checks to see how well the medicine is working.

I agree to provide primary care for you even if you are no longer getting controlled medicines

from me.

Patient’s signature

Date

Resident Physician’s signature

Attending Physician’s signature

This document has been discussed with and signed by the physician and patient. (A signed

copy stamped with patient’s card should be sent to the medical records department and a

copy given to the patient.)

Sample Patient Agreement Forms Page 5