Supervised consumption client agreement form
Patients Name………………………..
Key Worker……………………………
Contact number………………………..
You must:
The Pharmacist will:
Why?:
Ensure that you have read a copy of
the Patient Information Leaflet of the
medication you’re taking as part of the
supervised consumption scheme (if
appropriate).
Explain the contents of the
Patient Information Leaflet (if
appropriate) if you have any
queries and concerns regarding
the information contained in them.
This is to enable you to
understand more about the
medication you are taking.
Attend the pharmacy daily (except on
days when pharmacy is contracted to
close) within the agreed times of,
……………………………………at the
designated counter which will be
explained to you by the pharmacist on
your first visit to the pharmacy.
Not attend whilst under the influence
of alcohol and/or drugs.
Provide a confidential space for
your supervision. Inform you of
the opening days and times of the
pharmacy and any relevant
changes to it.
To use quieter times in the
pharmacy so that you may
receive your dose as quickly as
possible and away from the
gaze of other people.
Refuse to dispense your
prescription and refer you back to
the clinic or surgery if you attend
the pharmacy whilst under the
influence of alcohol or drugs.
Keep records of your attendance
and will refer you back to the
clinic if your collection is erratic.
The pharmacist will refuse to
dispense your prescription on this
basis.
Treat you with respect.
You may be at risk of overdose
and death if you use
methadone or buprenorphine at
the same time as other drugs or
alcohol.
Pharmacists have a
responsibility as part of your
care team to help monitor your
treatment.
Attend the clinic or surgery for
reassessment if you have not
attended the pharmacy for 3
consecutive days or more.
Attend alone (including leaving pets
outside), and treat the pharmacist and
their staff with respect.
Not allow any other person to attend
on your behalf to collect your
prescription unless previously
arranged with the clinic and
pharmacy.
Not accept any notes or phone
calls from a third party asking for
your prescription to be given to
someone else unless previously
arranged with the clinic.
Not ask the pharmacist to supply a
quantity of methadone /
buprenorphine other than that
prescribed for any specific day
Dispense methadone /
buprenorpine in accordance with
the prescription.
Be aware that the pharmacist may
have to pass on necessary
information about you to other
professionals.
Inform you if they feel it
appropriate to pass on necessary
information to other professionals.
Provide health information and
education to support you during
your programme.
The pharmacist wants to help
you and will treat you with
respect and courtesy if you
respect them.
This is to ensure you receive
your methadone or
buprenorphine dose. The clinic
will work with the pharmacist to
make different arrangements if
necessary.
By law, pharmacists must
supply exactly what has been
ordered and on the days
specified on your prescription.
The pharmacist wants to help
you gain increased
independence and social
acceptance by supporting you
through this programme.
Client’s Signature……………………………………Date……………………………
Pharmacist’s Signature…………...………….…….Date……………………………