Pain Medicine Associates, staff and myself have a common treatment goal: to improve my ability of function and/or work. In consideration of that goal, I may be treated with potent medications. These medications are controlled substances and therefore monitored by local, state and federal agencies. These medications are highly effective when taken as directed under medical supervision, but they also have potential for misuse and abuse.
I THEREFORE AGREE TO ABIDE BY THE FOLLOWING CONDITIONS:
I agree that only Pain Medicine Associates physicians shall prescribe all medications for the control of the pain related to my condition. I agree to inform my Pain Management physician if I obtain a prescription for pain control from any other source for any reason.
I understand that certain medications may interact with others, therefore, I agree to inform Pain Medicine of ALL medications I am taking for any other medical condition. I also agree to update them if any changes are made to these medications.
I understand that my medications are prescribed to be used by myself only and I agree not to “share” or give my medications to anyone else. This is illegal, as well as dangerous for the other person. I agree to use my prescriptions exactly as written including the prescribed dose, time, interval or frequency, and route. If I take my medication more often and use up my medications sooner than prescribed, I understand that they will not be refilled early.
I understand that some patients may develop tolerance, which is the need to increase the dose of medication to achieve the same effect in terms of pain relief. I understand that as a result of other treatment, therapy, or the natural course of my disease process, my pain may change. Therefore, my medication doses will have to be adjusted (increased or decreased) as deemed appropriate by my physician. I will not adjust the medication by myself.
I understand that some of the medications prescribed for my pain conditions are controlled substances and therefore have the potential for physical and psychological dependence. If this happens, I will follow my physician’s guidance and participate in any treatment programs prescribed, which may include medical treatment, psychological counseling and detoxification.
I am responsible for my pain center prescriptions and medications. I will not expect my prescriptions or medications to be replaced should they be lost, misplaced or stolen for any reason.
I understand that to stop taking the medications abruptly may be dangerous and lead to withdrawal symptoms. If medications need to be discontinued, I will do so gradually and only under medical supervision by my Pain Management physician.
I will report stolen medication to the police. I am responsible for keeping track of the amount of medication left and plan ahead for arranging the clinic visit to have my medications refilled.
I agree to periodic random drug screening at the discretion of Pain Medicine Associates physicians. This must be done when requested by my physician in order to promptly assess the effectiveness of my medication, as well as compliance.
I agree to use one pharmacy for filling all my prescriptions. I understand that in an emergency I could use a different pharmacy. If I do use or change pharmacies for any reason, I will notify Pain Medicine Associates.
I understand that if I violate any of the above conditions, my obtaining prescriptions and/or treatment of Pain Medicine Associates will be terminated.
If the violation involves obtaining controlled substances or any prescription for my pain condition from another individual or any illegal activity such as altering a prescription, the incident may also be reported by my Pain Medicine physician to other physicians caring for me, local police department, pharmacies and other authorities such as Drug Enforcement Agency, etc. as appropriate for the situation.
Medication refills will only be handled through a clinic visit. Contact Pain Medicine Associates at (423) 232-6120 to schedule an appointment.
Please give Pain Medicine Associates four days advanced notice. This agreement will supersede all other agreements.
By signing below I indicate that I agree with all terms and conditions for this contract. I have received a copy of this for my own records.
Patient: ________________________________________________
Physician: ______________________________________________
Witness: ________________________________________________