Opiate Pain Management Agreement Template

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El Paso Integrated Physicians Group, P.A.
Opiate Pain Management Agreement
The purpose of this agreement is to improve communication and prevent misunderstanding about the medications
you are taking to treat your chronic pain. The medications listed below require close monitoring. They should be
taken as directed by your doctor. You should also follow any other directions your doctor has given you about
managing your pain. It is your responsibility to report your use of the medications and how they affect you
accurately. It is your provider’s responsibility to provide options that will improve your pain level.
MEDICATION
DOSE
DIRECTIONS
QUANTITY PER MONTH
__________
_____
___________
____________________
__________
_____
___________
____________________
__________
_____
___________
____________________
Please initial next to each statement to which you agree.
_____
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 the medications stated above may change. There may be additions to therapy and I may
be asked to stop a medication. This agreement does not bind me to the specific medications listed above.
_____
I will communicate fully with my doctor about the character and intensity of my pain, the effect of the
pain on my daily life, and how well the medicine is helping to relieve the pain.
______ I have the right to have my pain evaluated regularly and my treatment adjusted as appropriate.
______ I have the right to stop taking a medication, but I must consult with my doctor first.
______ I will not use any illegal controlled substances, including marijuana, cocaine, etc., nor will I misuse or self-
prescribe/medicate with legal controlled substances. Use of alcohol will be limited to time when I am not
driving, operating machinery and will be infrequent.
_____
I will not share my medication with anyone.
_____
I will not attempt to obtain any controlled medications, including opioid pain medications, controlled
stimulants, or anti-anxiety medications from any other doctor.
_____
I will safeguard my pain mediation from loss or theft. Lost or stolen medications will not be replaced.
_____
I agree that refills of my prescriptions for pain medications 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.
_____
I agree that I will submit to a blood or urine test if requested by my doctor to determine my compliance
with my program of pain control medications. The test will be done within 24 hours of my doctor’s
request.

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