Pain Management Agreement Template Page 2

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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.
I agree to use ________________________________________________ Pharmacy
located at __________________________________________________________,
telephone number
__________________________________________________________, for filing
prescriptions for all of my pain medicine.
I authorize the doctor and my pharmacy to cooperate fully with any city, state or federal
law enforcement agency, including this state’s Board of Pharmacy, in the investigation
of any possible misuse, sale, or other diversion of my pain medicine. I authorize my
doctor to provide a copy of this Agreement to my pharmacy. I agree to waive any
applicable privilege or right of privacy of confidentiality with respect to these
authorizations. ____________
I agree that I will submit to a urine or blood test if requested by my doctor to determine
my compliance with my program of pain control medicine. _____________
I agree that I will use my medicine at a rate no greater than the prescribed rate and the
use of medicine at a greater rate may result in being without medicine for a period of
time.__________
I agree to follow these guidelines that have been fully explained to me. All of my
questions and concerns regarding treatment have been adequately answered. A copy of
this document has been given to me. ____________
This Agreement is entered into on this ________________day of _________,_________.
Patient Signature: _______________________________________
Physician Signature: ______________________________________
Witnessed by: ____________________________________________

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