FOR THE USE OF CHRONIC OPOIDS AND OTHER CONTROLLED PRESCRIPTION MEDICINES

My provider and l, have decided to try and relieve my chronic pain or other symptoms needing controlled medicines, to improve my function and quality of life. I recognize that whereas these medicineshave possible benefits, some of them, off-label use (not FDA approved), do have side effects, some serious. My provider and or his staff have explained to me in detail the side effects and I have been given the opportunity to ask any questions I may have. The medicines are only one component of my treatment regimen. I appreciate that in order to receive continuing care by my provider for my symptoms, I will adhere to the following mutual expectations:

I WILL NOT:

Suddenly stop taking these medicines

Use them for uses other than treating my pain

Increase the dose without discussing with my provider Share them with others

1. Pain medicines will be used only as directed for my pain.

2. I will receive controlled medicines only from my provider and from no one else, including ER visits and Hospital stays.

3. I will have my prescriptions filled ONLY AT ONE pharmacy of my choice, which I have clearly specified with my provider.

4. I will ask my provider or pharmacy for refills on a predetermined schedule, only asking when I still have no more than two days' worth of medication remaining.

5. No refills will be dated before the 30-day period.

6. Some controlled prescription medicines (those required by law) will be given only at my provider's office. They WILL NOT be mailed.

7. I will adhere to random drug testing.

8. It is my responsibility to protect my prescription from loss, theft, or damage. A police report will be required by any report of theft before my provider will consider replacing them. If a second loss, theft, or damage occurs; my provider may choose not to replace them.

9. These pain medicines are only one component of my treatment regimen. I agree to adhere to other aspects of my care as discussed with my provider.

10. I agree to see my provider at lease every 3 months for monitoring whether or not I have insurance to cover the cost of the visit.

11. Violation of this agreement will be grounds for TERMINATION of the patient-provider relationship and for the CONTROLLED SUBSTANCE CONTRACT.

12. PATIENT AND OR OTHER PERSON PICKING UP A PRESCRIPTION MUST SHOW ID AT THE TIME OF PICKUP.

Patient Name:Patient Signature:

Date: Provider Signature:

If person is not on this form they MAY NOT be allowed to pick up the prescription. Persons allowed to pick up prescriptions: