Medication Log Page 2

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ROBERT P. SOTTA, M.D.
PRESCRIPTION AGREEMENT
Patient:____________________________________________________
DOB:___________________________
GENERAL PRESCRIPTIONS
I understand that I am to select one pharmacy and call them directly for refills at least 2 business days
ahead of time. There will be no refills called in after 5:00pm Monday through Friday and not at all on
weekends so I will plan accordingly to ensure that I do not run out of medications necessary for my medical
treatment. I am also aware that some prescriptions can only be given in writing and may require extra time to
pick up or receive in the mail.
ANTI-INFLAMMATORY DRUG PRESCRIPTIONS (NSAID’s)
I understand that NSAID’s do not take effect immediately and that it may be up to a week before I see results.
NSAID’s can cause gastrointestinal problems such as diarrhea or upset stomach, as well as drowsiness.
Although this is rare, I will take them at home for the first time to see how I react. I agree not to take any other
over-the-counter drugs such as Advil, Aleve or Ibuprofen. Tylenol, if needed, will be fine.
NARCOTIC PRESCRIPTIONS
I understand if I am receiving narcotics to treat my medical condition that there are RISKS associated, such as
dependence, addiction, constipation, coordination, bowel obstruction, loss of sexual desire and performance,
as well as changes in my appetite, sleep habits or personality.
Respiratory depression can also be caused by narcotics. This can lead to shortness of breath, especially in
heavy smokers and in people with lung disease. I will inform you of my smoking practices so that we can
discuss the risks to me.
Medication interactions can increase the risks associated with narcotics. The most important of these is
alcohol. I will inform you of my drinking practices so that we can discuss the risks associated with drinking and
taking narcotics. I will inform you of all medications I am taking while on narcotics, including those obtained
“over the counter”, as there may be interactions between them and the narcotics I am taking.
To minimize Risk(s) and to ensure adequate supervision, I AGREE:
to return for regular follow up visits at the time required by my physician.
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to report any change in mental state or any adverse reactions.
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To have any lab tests you advise, including blood levels and urine drug screening, and to
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comply with any consultations you deem necessary.
to provide or assist in obtaining any medication records deemed necessary by my physician.
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I agree NOT to mix alcohol with narcotics.
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I agree NOT to stop my medications suddenly because that could result in rebound pain and
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withdrawal symptoms.
I agree NOT to obtain any narcotics from any other physician unless you are notified.
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I understand that if my narcotic medication is lost, stolen, destroyed, used up early, etc., I will not refill it until it
is time for my next refill, no matter what the circumstances.
Patient or Legal Guardian Signature:_____________________________________Date:_________________

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