Narcotic Contract Template
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1
2NARCOTIC CONTRACT
The purpose of this contract is to maintain a safe, controlled treatment plan. I am asking for
have
narcotic pain medication because other treatments and medications I
received have not
given enough pain relief. It is unlikely that any medication will completely take away my pain,
but for humane reasons, narcotic pain medication will be given to me as long as my pain
continues, provided that I follow the terms of this contract.
I understand that the possible complications of chronic narcotic therapy include:
•
chemical dependence (addiction)
•
constipation, which could be severe enough to require medical treatment
•
difficulty with urination
•
drowsiness
•
nausea
•
itching
•
slowed respiration
•
reduced sexual function
If I take more medication than what is prescribed, a dangerous situation could result, such coma,
organ damage, or even death. I understand that if I run out of my medication too soon, or if my
medication is stopped suddenly, I could have narcotic withdrawal symptoms which can be very
uncomfortable or dangerous. If I become pregnant, there are known or unknown risks to the
unborn child which include narcotic addiction and the possibility of the baby experiencing
narcotic withdrawal at birth. I am obligated to let my doctors know if I am pregnant, and they will
help me find ways of controlling my pain without narcotics.
The terms of this contract include the following:
1. Only one pharmacy will be used for filling narcotic prescriptions,
The pharmacy you have selected is:
____________________________________________________________
Phone #: ___________________________________________________
2. If it is found that I received a prescription for narcotic medications from a source other
than _(doctor/clinic) I will be discharged from _(doctor/clinic)
and any prescriptions
,
for narcotic medication will be discontinued.
3. It is necessary to call _(doctor/clinic) Monday through Friday (9:00 a.m.-5:00 p.m.) to
refill medications. It is important to make sure that I have enough medication to get
through the weekend or after hours.
4. The physician on call or after hours and on weekends will NOT fill my medications.
They do not have charts available for review to make decisions regarding medications.
5. I agree and will sign a release to allow _(doctor/clinic) doctors to communicate with my
referring physician, primary care physician and any pharmacists regarding my use of
medications.
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