CONTROLLED SUBSTANCE CONTRACT
INITIAL EACH BLANK AND SIGN AT THE BOTTOM OF THE PAGE
Controlled substance requires close monitoring for safety and its effectiveness. Only one (1) month of controlled substance medication will be
written at the time of your appointment.
_____Monthly visits are required
_____No early refills
_____No replacement of medication due to spilled, lost or stolen
_____No use of Alcohol
_____No use of illicit drugs
_____No selling or sharing of medication
_____I will only use one Doctor and one Pharmacy to fill my medication
_____I agree to a random Drug Screen whenever my provider feels it is necessary
_____I agree to take prescribed medication as directed by my provider
_____I authorize my provider to check the PDMP (Colorado Prescription Drug Monitoring)
_____I will provide all of my old medical records by my second office visit or I may not be seen
_____I understand that controlled medication can cause physical and/or psychological dependency. If I suddenly stop or decrease the
medication, I could have withdrawal symptoms (flue like symptoms such as nausea, vomiting, diarrhea, aches, sweats, and chills) that may
occur 24-48 hours after the last does. I understand that controlled substance medication withdrawal is uncomfortable but not life threatening.
_____I understand if I am pregnant or become pregnant while taking any controlled substance medication, my child could potentially become
physically dependant on the medication and when born could go through withdrawals and could be life-threatening.
_____I will not drive a motor vehicle or operate machinery if I experience drowsiness, sedation or dizziness, which could put my life or someone
else’s life in jeopardy.
I authorize Wheatridge Family Clinic and my pharmacy to cooperate fully with any law enforcement agency in the investigation of any possible
misuse or other diversions of my medication. I authorize Wheatridge to provide a copy of this contract to my pharmacy and to my insurance
company. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations.
I understand any resistance or manipulation of this system may constitute in immediate dismissal from Wheatridge Family Clinic. I also
understand that any verbal confrontation, verbal manipulation, or threats in person or over the phone will constitute immediate dismissal from
Wheatridge Family Clinic and will be reported to the local authorities and my insurance company.
I understand that if I break any part of this contract, my provider will start tapering me off the medication over a period of several days, as
necessary, to avoid withdrawal symptoms. I will not receive any more controlled substance medication and I will be dismissed from the
practice.
_________________________________________________
_____________________________________
Signature of Patient
Signature of Provider
Date
Date
By initialing all the required areas and my signature, I agree to all the terms set forth in this contract. I understand that if I break any of the
terms, I may be dismissed from Wheatridge Family Clinic and I’ll need to find another provider within thirty (30) days.