Your pain is very important to us. We want to help you control your pain in the best way we can. The goals for using this medication are (1) to relieve suffering, (2) to improve sleep and functioning during the day and (3) to work along with other treatments to allow your body to heal as much as possible.
I____________________________________________(the patient) voluntarily agree to this plan with Heartland Community
Health Clinic, so that I can use prescription and other controlled drugs to manage my pain or anxiety.
I also understand that state and federal laws and regulations control the use of these pain medicines. My providers must follow these laws. I will follow this plan to treat my pain and anxiety with these medicines.
1.
The pain medicine(s) I will be taking have some risks and may cause side effects.
Some of these are:

Skin Rashes

Sleeping Problems


Sexual Problems
Sweating

Constipation

Changes in how clearly you think
 Using too much medicine can make you very sleepy and can slow your breathing rate.
2.
I will let my provider know if I am having any of these or other side effects.
3.
I understand that if I take these pain medicines for a long time, they will not work as well as they did when I first started taking them.
4.
Using narcotic pain or anxiety medicine may cause my body to become dependent on the medicine. This means that if I stop taking the medicine, or take a smaller amount, I may have withdrawal symptoms.
These symptoms may include:

Nausea


Stomach Cramps
Vomiting

Chills


Diarrhea
Nervousness

Sweating

Seizures

Mood Changes
5.
Only one provider should be coordinating and changing my pain medicine and I agree this will be my Primary Care
Provider. I will not go to the Emergency Room or any other provider to get my pain medicine.
6.
I agree to take the pain medicine exactly as my Primary Care Provider has ordered. I will not change the amount of medicine, or how often I take it.
7.
* I agree to be checked by my Primary Care Provider on a regular basis, and I will come to all of my appointments.
* The pain medicines given to me at each visit are supposed to last as instructed by the
provider. My pain medicine will not be refilled early.
* I understand that it is a felony to alter or forge prescriptions.
8.
I agree to have all my prescriptions filled at only one (1) pharmacy. PHARMACY: __________________________
9.
I agree to keep my medicine in a safe place. If I lose my medicine, or it is stolen, I understand that I will not get medicine to replace the ones that have been lost.
10.
I agree not to sell or give my medicines to anyone.
11.
If I break the rules and alter or forge prescriptions, get pain or anxiety medicine from another doctor, take more medicine than I should, give my medicine to others, or break this agreement in some other way, my pain and anxiety medicines may be reduced and then stopped. I may no longer be able to come to Heartland.
I understand that my signature serves as consent to share medical information with pharmacies, other health care providers and other agencies (i.e., mental health, law enforcement, PT).  I received a copy of this agreement.

I have read this agreement and/or it has been explained to me. My questions about this agreement have been answered. I understand this plan. I know that if I break these rules my doctor can stop my pain medicine.
________________________________
PATIENT SIGNATURE
________________________________
PATIENT NAME (print)
____________
DATE
________________________________
PCP SIGNATURE
________________________________
PCP NAME (print)
____________
DATE