Prescription Contract Template printable pdf download

David K. Lee, MD

146 North Hospital Drive, Suite 350

Subhash J. Patel, MD

West Columbia, SC 29169

J. Eric Ashton, PA-C

(803) 936-7966 • FAX: (803) 936-7938

A Lexington Medical Center Physician Practice

Prescription Contract

Date:

Patient Name:

DOB:

____________________

____________________________________________________________________

__________________

The conditions of this agreement follow nationally accepted standards of care for managing patients on chronic pain medications.

Narcotics, pain medications, tranquilizers, barbiturates and sleeping pills are very useful but have a high potential for misuse.

There is also a risk of developing an addiction or of a relapse occurring in a person with a prior addiction. Because these medicines

have potential for abuse or diversion, strict accountability is necessary for prolonged use.

Local, state and federal governments, therefore, closely control them. They are intended to relieve pain or to improve function

and/or ability to work. Such medications are not used to simply feel good. This is for your safety, protects your access to controlled

substances, and protects your provider’s ability to prescribe for you.

, agree to the following conditions because my physician is prescribing

_________________________________________________________

such medication for me to help manage my pain/anxiety/etc.

 1. I understand that all controlled substances must be prescribed by the assigned provider or his/her selected representative at

Southeastern Orthopaedic and Sports Medicine. My assigned provider is

______________________________________________________

 2. I will obtain all controlled substances from the same pharmacy. If I need to change pharmacies, I will notify this office.

The pharmacy I have selected is:

Phone:

___________________________________________

_________________________________________

 3. I understand that it is my responsibility (as the patient) to make sure my pharmacy has my medicine in stock. Prescriptions will not

be rewritten due to out of stock issues.

 4. I will inform this office of any new medications I take or of any bad side effects I experience from my medication. I will also inform

this office of any new medical condition I may develop.

 5. I give my provider permission to discuss my diagnosis and treatment details with my pharmacists or other professionals who

provide health care for purposes of maintaining accountability.

 6. I will not share, sell, or permit others to have access to these medications.

 7. I will inform other health care providers of my medications.

 8. I will not increase my medication use, alter a prescription or change the prescribed schedule for taking my medication without the

approval of my doctor.

 9. I will not use any illegal drugs or obtain drugs illegally.

 10. I agree to random blood screens and/or random urine screens. If there are unauthorized substances, or if my prescribed

medication is not present, I may be referred for assessment for addictive disorder and/or I maybe discharged from this office.

 11. I will keep my medicine and prescription safe as these medications may be sought by other people who have chemical

dependency. I will not leave my prescription or medicine anywhere someone could take them. I will make sure to keep this

medicine out of reach of pets, children, or anyone else, since these medicines may hurt or kill someone.

CONTINUED ON BACK

8528-024-1 (Rev. 2/2015)

Prescription Contract Template

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