CONTROLLED SUBSTANCES AGREEMENT

I, a patient of the Provider, understands that the Provider may utilize controlled substances (schedule II - V) as part of my treatment. In addition, my Medical Professional has the sole discretion to determine whether or not to prescribe any medication that may be addictive.

I understand I will not have my medications replaced if they are lost or stolen.

For an after hours emergency, including withdrawal symptoms, overdose or loss of medications, I will go to the emergency room. I understand my Provider is not available outside of regular business hours. 

I understand my Provider is not available to alter my medication schedule or dosage outside of scheduled appointments. 

I will obtain all medication from the same pharmacy and will inform the Provider of the name of that pharmacy.

I will inform the Provider if I have been prescribed any controlled substances by a provider outside of this clinic.

My provider may provide tapering of medications if required, under the sole discretion of the provider.

I understand that a prescription may be given early if the Medical Professional or the patient will be out of town when the refill is due. These prescriptions will contain instructions to the pharmacist that the prescriptions(s) may not be filled prior to the appropriate date.

If the responsible legal authorities have questions concerning my treatment, as may occur, for example, if I obtained medication at several pharmacies, all confidentiality is waived, and these authorities may be given full access to my full records of controlled substances administration.

I understand that I may be asked to bring my medications in their original container to the Provider clinic while I am on any controlled medication.

I understand that failure to adhere to these policies and/or failure to comply with Medical Professional’s treatment plan may result in cessation of therapy with controlled substance prescribing by this Medical Professional or referral for further specialty assessment, as well as possible discharge from the practice.

I, the undersigned patient, attest that the foregoing was discussed with me, and that I have read, fully understand, and agree to all of the above requirements.