Pain Management Agreement Template


R. Michael Hullander, M.D.
Ralph Mozingo, D.O.
David Pires, D.O.
Jamie Duncan, P.A.
Britney Fedor, P.A.
Matthew Ebling, P.A.
The purpose of this agreement is to prevent misunderstanding about certain medicines
you could be taking for pain management. This is to help you and your doctor to comply
with the law regarding controlled pharmaceuticals.
I understand that this Agreement is essential to the trust and confidence necessary in a
doctor/patient relationship and that my doctor undertakes to treat me based on this
agreement. ________
I understand that if I break this Agreement, my doctor may stop prescribing these pain-
control Medicines.___________
In this case, my doctor will taper off the medicine over a period of several days, as
necessary, to avoid withdrawal symptoms. Also, a drug-dependence treatment program
may be recommended.________
I will communicate fully with my doctor about the character and intensity of my pain,
the effect of pain on my daily life, and how well the medicine is helping to relieve
I will not use any illegal controlled substances. ____________
I will not share, sell, or trade my medication with anyone. _____________
I will not attempt to obtain any controlled medicines, including opioid pain medicines,
controlled stimulants, or anti-anxiety medicines from any other doctor. _____________
I will safeguard my pain medicine from loss or theft. Lost or stolen medicines may not be
replaced. __________
I agree that my refill of my prescriptions for pain medicine will be made only at the time
of an office visit or during regular office hours. No refills will be available during
evenings or on weekends. ___________ We also require a 72 hour notice to be able to
refill any medicine. ________


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