Charles Bradley Sisson, M.D.
Fellowship Trained in Pain Management
Board Certified: American Board of Anesthesiology
Board Certified: American Board of Pain Management
Jaclyn Summers, PA-C
Danielle Dickman, PA-C
Eric Hofmann, PA-C
Doug Larner, APN
3810 North Grant Avenue
Loveland, CO 80538
Telephone: (970) 221-9451
Fax: (877) 535-9359
3000 Center Green Drive, Suite 120
Boulder, CO 80301
Telephone: (303) 444-4141
Fax: (877) 535-9359
2001 70th Ave. Suite #300
Greeley, CO 80634
Telephone: 970-396-6994
Fax: (877)535-9359
INFORMED CONSENT FOR OPIOID TREATMENT
Opioids, (Pain medications such as Morphine, Vicodin, Percocet, etc…) are very useful, but have a potential for misuse and are therefore closely monitored and
controlled by the local, state, and federal government. Because our physicians prescribe such medication to help manage pain, we need you to read and follow these
policies. Failure to abide by any of these conditions will be considered a breach of agreement, and may result in the termination of the patient-physician relationship.
You are responsible for your medications. By signing this agreement, you agree to take the medication ONLY as prescribed and to contact us before making any
changes.
Increasing your medication without the close supervision of a physician could lead to drug overdose, severe sedation, respiratory distress, and/or death.
Decreasing or stopping medication without the close supervision of a physician could cause withdraw. Withdraw symptoms include: yawning, sweating, watery eyes,
runny nose, anxiety, tremors, aching muscles, hot and cold flashes, “goose bumps”, abdominal cramps, and diarrhea. These symptoms can occur 24-48 hours after the
last dose and can last up to 3 weeks.
Common side effects related to taking opioid medications include: vomiting, drowsiness, and constipation. Less common side effects are: mental slowing, flushing,
sweating, itching, urinary difficulty, and jerkiness. Side effects may occur at the beginning of your treatment, and often will subside in a few days. It is your
responsibility to notify the physician of any side effects that continue or that are severe.
Notify our office immediately if you go to the emergency room or see another physician for pain, or if you become pregnant.
Prescription medications are for the use of the person whose name appears on the label only. Prescription medication should NEVER be given to others. If children
are in the house, child-proof lids are required on all medication bottles.
Contact our office before taking ANY other medication (prescription, or over-the-counter) or herbal supplements. Combining opioids and benzodiazepines, sedatives,
anti-histamines, and some herbal supplements may produce profound sedation, respiratory depression, severe drop in blood pressure, and death.
You may NOT use alcohol or recreational drugs while taking prescribed opioids. If this happens, you will be terminated from the program.
You are responsible for your medication. Opioid prescription(s):

Can only be written for a one month supply.

Will always be filled at the same pharmacy (your choice, listed on this agreement).

Will be filled only with an appointment during regular office hours Monday through Thursday.

Can be picked up in person only.

Refills will NOT be given after hours, on weekends, or holidays.

Will NOT be replaced if the prescription is lost, spilled, or misplaced.

Will be taken only as prescribed by my physician.

Refills will not be treated as an emergency. You are responsible for keeping track of when you will run out. Please call at least one week before you run
out to make an appointment for refills.

If your medication is stolen, report it to the police department and obtain a stolen item report. Replacement prescriptions may be given at the sole
discretion of the physician, and only with appropriate documentation.
COLORADO PAIN CLINIC

If you use a mail order pharmacy, you MUST send your prescriptions by certified mail. We cannot be held responsible for the pharmacies timeliness or for
the delivery by the US post office, or any other delivery service. You can always fill your prescriptions at a local pharmacy. Replacement prescriptions
may be given at the sole discretion of the physician, and only with appropriate documentation.
While physical dependence is to be expected after long-term use of opioids, signs of addiction will be interpreted as a need for weaning and detoxification.

Addiction is a psychological and behavioral syndrome that is recognized when the patient shows drug “craving”, doctor or pharmacy “shopping”,
manipulation of a doctor or pharmacy to obtain drugs, or abuse of medication to get a “high”. Patients that show signs of addiction are not good candidates
for the opioid trial.

If you begin to exhibit such behaviors, your drug will be tapered and stopped.

Patients that display manipulative or illegal behaviors to obtain drugs may be discharged from the practice.
The physician’s treatment plan may include a time contingent use of opioids. If it appears to the doctor that there is no improvement in your quality of life or daily
functioning, then the opioids may be discontinued.
By signing this agreement, you agree:

To submit to drug screen testing as determined by the physician.

That if you do not follow the conditions stated in this document, the agreement is broken, and we will discontinue your opioid medications.

To make an appointment to have any questions or concerns about this agreement or your treatment addressed before a problem arises.

Not to request or accept controlled substances from any other physician or individual while you are receiving medication from the physicians at Colorado
Pain Clinic.
I authorize the release of information by the physicians and designees of Colorado Pain Clinic to my other health care providers, my pharmacy, and my insurance
company or other reimbursing agencies as designated.
I, _____________________________________________________, have read the above opioid agreement, or have had it read to me. I have received a copy of this
agreement, and have had all of my questions and concerns addressed to my satisfaction.
I agree to use ONLY this pharmacy:
_____________________________________________________
Pharmacy Name
_____________________________________________________
Pharmacy Address
_____________________________________________________
Pharmacy city, state, zip
_____________________________________________________
Pharmacy phone
I, hereby, give my consent to participate in opioid medication therapy.
_____________________________________________________
Patient signature
__________________________________________________________
Witness signature
_____________________________________________________
Physician signature
__________________________________________________________
Date
Revised 09/04/13