PAIN MANAGEMENT AGREEMENT
The purpose of this agreement is to prevent any misunderstandings about certain medications you will be taking for pain manag ement. This is to help both you and your doctor to comply with the laws regarding controlled pharmaceuticals. In this agreement, “this doctor”, is
Michele K. Coleman, DO of Michele K. Coleman, DO & Associates, Inc., 120 N 18 th St., Mt. Vernon, WA 98273.
I
(print full name)
___________________________ understand that this agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that this doctor undertakes to treat me based on this agreement.
I understand that if I break this agreement, this doctor will stop prescribing these pain controlling medications. In this case, the doctor will taper me off of the medications over a period of several days, as necessary, to avoid withdrawal symptoms. Also, a drug dependency program may be recommended.
I will communicate fully and honestly with this doctor about the character and intensity of my pain, the effect of the pain on my life, and how well the medications are helping to relieve the pain and allow me to perform my normal daily activities and improve my quality of life. I understand that pain medications are not a cure for pain and will not completely eliminate pain. In addition:
1.
I will not use any illegal controlled substances. I will not drink alcohol or consume marijuana while I am taking medications prescribed by Dr. Coleman.
2.
I will not share, sell, or trade my medications.
3.
I will not attempt to obtain any controlled medications, including opioid pain medicines, controlled stimulants or anxiety medication from another office without notifying Dr. Coleman’s office and obtaining her agreement.
4.
I will inform all medical professionals I interact with about this agreement.
5.
I will safeguard my medicines from loss or theft. Lost or stolen medications/prescriptions will not be replaced.
6.
I agree that refills on my prescriptions for pain medications will be made only at the time of an office visit during office hours. No refills will be available during evenings, weekends or holidays.
7.
I agree to use only ____________________________ pharmacy, located at _____________________________, phone number _________________, for filling all prescriptions of all my pain medications.
8.
I authorize this doctor and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including the State Board of Pharmacies, in the investigation of any possible misuse, sale or other diversion of my pain medications.
9.
I authorize this doctor to provide a copy of this agreement to my pharmacy and to other doctors who are participating in my treatment. I agree to waive any applicable privileges or rights of privacy or confidentiality with respect to these authorizations.
10.
I agree I will submit to a blood/urine drug screening, and/or pill count, if requested by this doctor to determine my compliance with my program of pain medication.
11.
I agree that I will use my medication only the way it was prescribed, at a rate no greater than the prescribed rate, and that misuse of my medication in any way will be reported immediately to Dr. Coleman.
12.
I will bring all unused medications to every visit.
I agree to follow these guidelines that have been fully explained to me. All of my questions and concerns have been adequately answered. A copy of this document has been given to me.
This agreement is entered into on this ________ day of ______________________
Patient’s signature: _____________________________________
Physician’s signature: ____________________________________
Michele K. Coleman, DO
Witnessed by: _____________________________________