Attachment 16
Name:
MR #
Doctor:
Pain Management and Controlled Substances Agreement
Pharmacy
Name:
Phone #:
Fax #:
Phone #:
Fax #:
Change in Pharmacy Date:
Pharmacy Name:
1
2
3
4
Medications
Included
5
6
7
8
in This
Agreement
Please review each of these statements with your doctor. Initial each one to indicate that you
understand and are willing to enter into this Agreement.
1
I will get my pain medication/controlled substances only from the doctor listed above.
2
I will take these pain medication/controlled substances only as they have been ordered by this doctor.
3
I will get my pain medication/controlled substance prescriptions filled only at the Pharmacy listed
above, and will inform this doctor if I need to change my Pharmacy for any reason.
4
I will tell this doctor about all of my health problems. I will be honest about my pain, how it affects my
daily life, and how well the medications are helping me.
5
I will bring all of my medications with me to each appointment with this doctor. This includes
prescriptions from other doctors as well as over-the-counter and herbal medications I have decided to
take.
I will tell this doctor if I go to the Emergency Department and get more pain medication/controlled
substances there.
I will tell the other doctors I see about this agreement and the pain medication/controlled substances I
am taking.
I will allow this doctor, or any other, to test my blood and urine. This is to confirm that I am taking only
my pain medication/controlled substances as prescribed and nothing more.
6
7
8
9
10
11
12
I will not change how I take my pain medication/controlled substances without first talking with this
doctor.
I will not share, sell or trade my pain medication/controlled substances and I will protect them from
being lost or stolen.
I will not use any illegal drugs, including cocaine, heroin, etc. Any use of Marijuana will be
communicated to the clinician at the execution of this agreement and/or at the start of any new
treatment that includes medical Marijuana.
When I refill my pain medication/controlled substance prescriptions, I will not ask for early refills, even if
I lose or misplace my pain medications.
13
I know that pain medications/controlled substances with narcotics can be addictive. This means that
my body may need more and more medication or that it can be hard to stop taking these medications.
14
I know that pain medications treat only my pain, but not the cause.
15
I know that this doctor may ask me to get lab work, diagnostic tests or refer me to a specialist.
16
I know that this doctor may ask me to see a Behavioral Health Specialist (Psychiatrist) to help with my
pain issues.
17
I know that this doctor may recommend that I enter a drug dependence treatment program.
18
I know that pain medications/controlled substances can cause side effects that may make me sleepy or
slow down my reflexes. This can make it unsafe to drive a car or use machines.
19
I know that drinking any alcohol while taking my pain/controlled medications can make these side
effects worse.
I know that this doctor may give a copy of this Agreement to my Pharmacy, other doctors in this
Medical Group and the local Emergency Departments.
20
21
All of my questions and concerns regarding my treatment and this Agreement have been answered
fully and to my satisfaction.
22
A copy of this Agreement has been given to me.
23
This doctor and I have talked about my pain medications/controlled substances. I understand that I
must follow this agreement. If I do not, this doctor or others in the same clinic will not prescribe pain
medications/controlled substances for me. I understand that they can also refuse to provide any of my
medical care if I do not follow this agreement.
1. This Agreement is entered into on the __________day of the ____________ month of the year ____________
Patient Signature:
Clinician (must be the same clinician listed above)
Signature:
Witnessed
By:
Witness Signature/Title:
Please Print
2. This Agreement is updated and entered into on the _______day of the ________ month of the year ________
Patient Signature:
Clinician (must be the same clinician listed above)
Signature:
Witnessed
By:
Witness Signature/Title:
Please Print
3. This Agreement is updated and entered into on the _______day of the ________ month of the year ________
Patient Signature:
Clinician (must be the same clinician listed above)
Signature:
Witnessed
By:
Witness Signature/Title:
Please Print
4. This Agreement is discontinued on the __________day of the ____________ month of the year __________
Patient Signature:
Clinician (must be the same clinician listed above)
Signature:
Witnessed
By:
Witness Signature/Title:
Please Print