Patient Label
Patient (or Guardian) Care Agreement
NAME OF MEDICATION
DIRECTIONS
QUANTITY
PER MONTH
The purpose of this agreement is to make sure that you understand all of the rules that apply to taking this/these
medicines, as well as some of the risks. This information is very important for your safety, well being, and
successful management for your condition.
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I understand this/these medicine(s) have risks, and by signing this, agree I have received the ‘controlled
substances’ information sheet explaining this.
I will follow through with all referrals made by my provider.
I will see only this provider for this medical condition, unless the provider refers me to another or is
ill/away.
I will make and keep my appointments with my provider.
I will use only one pharmacy for this/these medication(s): ______________________________________.
I will not share this/these medication(s).
I understand lost or stolen medications or prescriptions will not be replaced.
I understand pharmacy records (from any pharmacy) may be reviewed to confirm prescriptions.
Urine may be required at visits, or I may be called from home to give urine. If I refuse to give urine, or
tamper with urine, it will be considered positive (dirty).
I will not take any street drugs, or use any non-prescribed controlled substances while I am on this/these
medication(s). If my provider recommends against it, I will not drink any alcohol. If I have used or am
using any of these substances, I understand I may be referred for substance abuse treatment and may be
required to give written proof of attendance to my provider in order for my treatment to be continued.
Medications will only be refilled during office hours, with 5 days notice.
Disruptive behavior or threats (or the appearance of this) toward staff and/or other patients will not be
tolerated and will result in discontinuation of the medication(s), and possible termination of care from
GVHC. Disruptive behavior can include excessive phone calling.
I understand that if I break this agreement, it will lead to my provider stopping prescribing this/these
medication(s).
My provider has the right to stop prescribing this/these medicine(s) if he/she decides that it is not helpful
for my problem or is harming me.
In order to obtain refills, the agreement I have with my provider is to:
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My goal (regarding this condition) is
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Additional comments____________________________________________________________________________
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Patient/Guardian Signature
____________________________
(Date)
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Provider Signature
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(Date)
Revised 2/15/11