Patient Agreement Form
Date: [date default="today"]
Patient Name: [text]
AGREEMENT FOR LONG TERM CONTROLLED SUBSTANCE PRESCRIPTIONS
The use of [text default="name of drug(s)"] may cause addiction and is only one part of the treatment for [text default="name of condition-e.g., pain, anxiety, etc."]
The goals of this medicine are:
[checkbox value="to improve my ability to work and function at home|to help my condition as much as possible without causing dangerous side effects | To maintain social and functional independence| To maintain an acceptable pain level and subsequent quality of life"]
I have been told that:
1. If I drink alcohol or use street drugs, I may not be able to think clearly and I could become sleepy and risk personal injury.
2. I may get addicted to this medicine.
3. If I or anyone in my family has a history of drug or alcohol problems, there is a higher chance of addiction.
4. If I need to stop this medicine, I must do it slowly or I may get very sick.
I agree to the following:
• I am responsible for my medicines. I will not share, sell, or trade my medicine. I will not take anyone else’s medicine.
• I will not increase my medicine until I speak with my doctor or nurse.
• My medicine may not be replaced if it is lost, stolen, or used up sooner than prescribed.
• I will keep all appointments set up by my doctor (e.g., primary care, physical therapy, mental health, substance abuse treatment, pain management)
• I will bring the pill bottles with any remaining pills of this medicine to each clinic visit.
• I agree to give a blood or urine sample, if asked, to test for drug use.
Refills will be made only during regular office hours—Monday through Friday, 8:00AM-4:30 PM. No refills on nights, holidays, or weekends. I must call at least three (3) working days ahead (M-F) to ask for a refill of my medicine. No exceptions will be made. I will not come to Primary Care for my refill until I am called by the nurse.
I must keep track of my medications. No early or emergency refills may be made.
I will only use one pharmacy to get my medicine. My doctor may talk with the pharmacist about my medicines.
The name of my pharmacy is [text default="Pharmacy name"].
Prescriptions from Other Doctors
If I see another doctor who gives me a controlled substance medicine (for example, a dentist, a doctor from the Emergency Room or another hospital, etc.) I must bring this medicine to Primary Care in the original bottle, even if there are no pills left.
While I am taking this medicine, my doctor may need to contact other doctors or family members to get information about my care and/or use of this medicine. I will be asked to sign a release at that time.
Termination of Agreement
If I break any of the rules, or if my doctor decides that this medicine is hurting me more than helping me, this medicine may be stopped by my doctor in a safe way.
I have talked about this agreement with my doctor and I understand the above rules.
As your doctor, I agree to perform regular checks to see how well the medicine is working.
I agree to provide primary care for you even if you are no longer getting controlled medicines from me.
Patient’s signature and Date
Medical Provider’s signature and Date
Result - Copy and paste this output: