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"]
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
This document has been discussed with and signed by the physician and patient. (A signed copy will be sent to the medical records department and a copy given to the patient.)
[checkbox memo="References (Hide/Show)" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).isNot('')"] Reference: A sample controlled substance agreement from drugabuse.gov [link url="https://drugabuse.gov" memo="link"][/conditional]
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