ADD/ADHD Medication Agreement
Patient name: ____________________________DOB:__________________ Date: _______________
The purpose of this agreement is to be certain that long-term controlled substances are prescribed in
the safest, most effective manner in compliance with current law. Utilization of controlled substances
may be medically useful but, if used inappropriately, carries risks. You must understand and agree to
the following terms in order for us to enter into a prescribing relationship. I understand that breaking
the terms of this agreement will mean my doctor will no longer prescribe controlled substances for my
condition. I understand that violating the terms of this agreement could result in discharge from the
practice.
I,
_____ (or my child), have been prescribed stimulant medication for
treatment of Attention Deficit / Hyperactivity Disorder (ADHD). I understand that when appropriately
prescribed for an individual with the documented condition, and used as directed, these medicines have
been shown to be generally safe and effective.
I further understand that this class of medications are controlled substances, strictly regulated by State
and Federal law, because of the potential for their misuse, abuse, and diversion. I realize that it is both
illegal and potentially very dangerous to share prescription medications or sell them to another person.
Mixing stimulant medications with other prescription medications, over-the-counter medications,
alcohol, or other drugs can be very dangerous. I agree to take my medication only as instructed by my
physician/provider and to not adjust the dosing on my own. I understand that it is a felony to obtain
these medications by fraudulent means, to possess these medications without a legitimate prescription,
and to either give or sell these medications to anyone else. It is my responsibility to protect and secure
both the prescription and medication safely so that they are not misplaced, lost, or misused by others.
Stimulant medications for ADHD can be obtained only through written prescription. Prescription
renewals are for a one month or, in limited circumstances, three month supply only. If a prescription is
lost, stolen, or damaged, or if the medication is misplaced, the prescription will not be rewritten prior to
the renewal date. If prescription or medication is stolen we advise you to file a police report to protect
yourself. Renewals will not be granted earlier than 3 days prior to the upcoming due date except in
extenuating circumstances such as studying abroad. Renewals are never given at night or outside of
normal office hours. I will obtain prescriptions at only one pharmacy or through one mail order
insurance plan unless I notify you that I change pharmacies.
This medication will be prescribed to me by Dr.
, or his/her associates. I
understand that Medication Management is only one facet of care for ADHD, and I will see a therapist or
mental health professional if recommended. If I am also seeing a mental health clinician for other
conditions that could impact the efficacy of the medication or the interpretation of symptoms, I will sign
January 2015
Page 1 of 2
ADD/ADHD Medication Agreement
Patient name: ____________________________DOB:__________________ Date: _______________
a release in order for mental health clinicians to communicate with you. I will not seek duplicate
prescriptions of the same medication from other doctors. I agree to notify my physician if there is any
significant change in my health status including pregnancy, or the prescription of any new medications
by another provider.
I agree to come in for office visits as requested by my doctor to monitor for positive and negative effects
of this medication. My provider will decide how often I need to be seen for office evaluation and
assessment. A urine drug screen may be requested prior to or while on this medication and refusal to
comply with this visit schedule or request for a urine sample may result in loss of ADD/ADHD
prescription privileges. I understand that periodic completion of ADHD Rating scales at the physician’s
office may be necessary and agree to complete them. Similar ADHD Rating scales may be intermittently
requested from my child’s teachers to monitor efficacy of therapy.
I have read and understand this agreement, and have had the opportunity to have all questions
answered to my satisfaction. I agree to use these ADD/ADHD medications under the terms of this
agreement. I understand that this agreement is essential to the trust and confidence necessary in a
physician/patient (family) relationship and that my physician will be treating me or my child based on
the terms of this agreement. I also understand that failure to abide by this agreement will result in the
termination of my stimulant medication prescriptions and possibly my discharge from the office for
future medical care.
Patient signature
(Or Legal Guardian)
January 2015
Date
Physician signature
Page 2 of 2
Date