Narcotic Contract Template (Page 2 of 2) in pdf

6. I will contact and communicate with _(doctor/clinic) about narcotic and other pain-

medications and side effects. I will NOT contact

physicians who do not work at _(doctor/clinic) regarding the above concerns. If I have a

significant side effect that occurs after hours or during the weekend, it is appropriate to

go to the emergency room at the nearest hospital.

7. I agree to take the narcotic medication exactly as instructed by _(doctor/clinic) doctors. I

am NOT allowed to change dosage amounts or alter the time schedule of taking the

medication without talking to a _(doctor/clinic) staff member.

8. I agree that _(doctor/clinic) will NOT replace any lost, stolen, or inaccessible narcotic

medications or narcotic prescriptions for any reason.

9. I must keep all regular follow-up appointments as recommended by _(doctor/clinic)

doctors. Failure to comply may cause discontinuation of narcotic prescriptions and

possible discharge from _(doctor/clinic) .

10. (doctor/clinic) will NOT accept telephone requests for narcotic prescriptions or refills

from anyone other than me.

11. All narcotic prescriptions must be picked up by me. If I

too disabled or sick, an

exception may be allowed at _(doctor/clinic) ‘s discretion.

12. I understand that the benefits of narcotic medications will be evaluated regularly using

the following criteria of pain relief:

a. -increase in general functions

b. -increase in life activities

c. -improvement in pain intensity levels

d. -absence of unacceptable side effects

e. -if appropriate, possible return to work and maintenance of a job

13. I agree to periodic urine screens for other medications and drugs if _(doctor/clinic)

physicians deem appropriate.

14. I have been given information about the use of narcotic medications and possible risks of

side effects including development of tolerance, dependence, addiction, and withdrawal

problems due to the medications, and I agree to undergo narcotic administration,

15. I agree to NOT hoard medication or alter the narcotic prescription. These behaviors and

other unacceptable behaviors will result in the discontinuation of narcotic prescriptions

and possible discharge from _(doctor/clinic) .

16. I agree to the following:

a. That I am NOT currently abusing illicit or prescription drugs and that I am not

undergoing treatment for substance dependence or abuse.

b. That I have never been involved in the sale, illegal pot session, or transport of

any drugs.

c. For women

That 1 am not pregnant and that I will inform the physician if I

only:

become pregnant.

This form has been fully explained to me, I have read it or have had it read to me, and I

understand and agree to the terms of this contract. If any part of this contract as outlined above is

broken, I understand that it will result in the immediate discharge from _(doctor/clinic) and

discontinuation of narcotic prescriptions.

________________________________________________

________________

Patient Signature

Date

_________________________________________________

_________________

Physician/Witness Signature

Date

Narcotic Contract Template Page 2

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