Prescription Contract Template (Page 2 of 2) in pdf

 12. I will bring my original containers of medicine to each clinic visit and may be asked to come in to the office at times other than my

scheduled appointments for a pill count.

 13. I may receive medications from other health care providers while hospitalized or in the ER, but I will not accept the prescriptions

for controlled medications upon discharge unless approved by my prescribing/pain clinic provider.

 14. I understand that my medicines will not be replaced if they are lost, spilled, destroyed or misplaced. If my medicine is stolen a

police report should be filed. Stolen drugs may or may not be refilled at the discretion of your provider.

 15. I understand that early refills will not be given. I am responsible for taking the medication in the dose prescribed and for keeping

track of the amount remaining.

 16. I understand that refills will only be given during designated office hours MONDAY through THURSDAY (8 a.m. – 3 p.m.). Refills

will not be made at night, on holidays or the weekends. Refills will not be made in “emergency situations” and should be called in

at least 24 hours in advance. I must come to my office appointments in order to have my medicines continued. No refills or dose

changes can be made after hours or on weekends. Appointments will be scheduled and failure to be compliant with this schedule

(for example, repeated cancellations or rescheduling or arriving late) may result in my being discharged from this office.

 17. I understand that if questions arise concerning my compliance with this agreement (for example, if I obtain my medicines from

several different pharmacies), responsible legal authorities may be given full access to my records regarding controlled substances

and confidentiality waived.

 18. I understand that if I do not follow these policies, my doctor will not be able to prescribe these medicines for me, my doctor will

discharge me from the clinic, and my doctor may not be able to refer me to another specialist.

 19. I understand that any medication treatment is a trial and that it will only be continued if I benefit from it. The goals of treatment

of pain with medications are to decrease pain, increase quality of life and increase level of function. If all of those criteria are

not met, medications may need to be adjusted or discontinued. Elimination of pain, while an ideal endpoint, is often not a

reasonable expectation.

 20. I understand that other treatment options such as non-opioid medication, injections, massage therapy, physical therapy,

psychological therapy, or psychiatric therapy may be recommended by my provider and that I will comply with the full scope of

multidisciplinary pain management as suggested.

 21. My doctor has the right to discharge any patient with 30 days notice at any time.

 22. I have received information from my provider on the risks and possible benefits from this medication treatment.

 23. I have read and understand this agreement and had a chance to ask questions. I agree to follow this policy.

Office Signature:

Date:

_____________________________________________________________________________

_________________________________

Provider Signature:

Date:

__________________________________________________________________________

_________________________________

Patient Signature:

Date:

____________________________________________________________________________

_________________________________

Prescription Contract Template Page 2