Opiate Pain Management Agreement Template (Page 2 of 2) in pdf

Opiate Pain Management Agreement Template Page 2

_____

I agree that I will use my medicine at a rate no greater than the prescribed rate and that use of my

medicine at a greater rate will result in my being without medication for a period of time.

_____

I will bring unused pain medicine to every office visit.

_____

I understand that if I break this Agreement, my doctor will stop prescribing these pain control medicines

and possibly discontinue treatment.

_____

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 agree to use: __________________________________________________(Name of Pharmacy),

located at: ______________________________________________, telephone no. _________________

for filling my 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 medication. I authorize my doctor to provide a copy of this Agreement to my

pharmacy and primary care physician.

_____

I agree to inform my pain management doctor of any other providers who prescribe medications for me. I

understand these providers may discuss my diagnoses and medications.

_____

I agree to follow these guidelines that have been fully explained to me.

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 _________________, 200_.

Patient Signature:_________________________________________________

Physician Signature: _______________________________________________

Opiate Pain Management Agreement Template Page 2