New Patient Medical History (Page 8 of 10) in pdf

13. Medications may not be replaced if they are lost or are destroyed. If your medication has been stolen and you complete a police

report along with a letter recounting the event regarding the theft, an exception may be made. Only one lost prescription or

medication will be replaced in a given calendar year.

14. Early refills will generally not be given. Renewals are contingent on keeping scheduled appointments. Please do not phone for

prescriptions after hours or on weekends as requests will not be honored.

15. If the responsible legal authorities have questions concerning your treatment, as might occur, for example, if you were

obtaining medications at several pharmacies, all confidentiality is waived and these authorities may be given full access to our

records of controlled substances administration.

16. It is understood that failure to adhere to these policies may result in cessation of therapy with controlled

substances prescribing by this physician or referral for further specialty assessment.

17. As per New York State Law, your doctor will check the State’s Prescription Monitoring program to verify your opioid

prescription history.

18. It should be understood that any medical treatment is initially a trial, and that continued prescription is contingent on evidence

of benefit. You agree that these medications may stop being prescribed if you:

A. Don’t show improvement in function

B. Behave in a way not consistent with the above responsibilities.

C. Give away, sell, or misuse the opioids

D. Develop an addiction problem from opioids

E. Don’t cooperate with responsibilities listed above, or refuse drug screening.

F. Experience a serious adverse outcome to treatment.

G. Don’t keep regular follow up appointments

19. The risks and potential benefits of these therapies are explained elsewhere [and you acknowledge that you have received such

explanation.

20. You affirm that you have full right and power to sign and be bound by this agreement, and that you have read, understand, and

accept all of its terms.

___________________________________________________________

______________________________________________________________

Patient’s Signature

Print Name

MD/NP Signature

Date

Weill Cornell Pain Medicine; Controlled Substances (Opioids) Safety Guidelines

Possible Side Effects of your opioids include but are not limited to:

Confusion, Nausea, Vomiting, Constipation, Dry Mouth, Low Testosterone, Central Sleep Apnea, Opioid Use Disorder and

Addiction, Aggravation or Depression, Breathing too slowly or overdose causing you to stop breathing.

You may also develop:

Psychological Dependence—it is possible stopping the opioids may cause you to miss or crave the drug

Tolerance—you may need more and more drug to get the same effect.

Addiction---Patients may develop addiction to opioids

Problems with pregnancy—if you are pregnant or contemplating pregnancy, discuss with your provider.

Stopping opioids abruptly may cause the following due to physical dependence:

Runny nose, abdominal cramping, diarrhea, sweating, nervousness, difficulty sleeping, rapid heart rate, goose bumps

It is recommended you keep a diary of the pain medications you are taking including doses, time you take the medication, time of

day, their effectiveness, and any side effects.

New Patient Medical History Page 8