Pain Management Agreement Template printable pdf download

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.

PAIN MANAGEMENT AGREEMENT

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

pain.__________

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. ________

Pain Management Agreement Template