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Medication controlled substance agreement

Medication & Controlled Substance Agreement (1)

We are committed to doing all that we can to treat your psychiatric conditions. In some cases, controlled substances are used as a therapeutic option in the management of such disorders, which is strictly monitored by both state and federal agencies. This agreement is a tool to protect both you and the prescriber by establishing guidelines, within the laws, for proper prescribing practices.
1. I will inform my prescriber of all medications I am taking, including over the counter medications, herbal remedies and medications from other prescribers, including my PCP. I will not seek prescriptions for my psychiatric medications from any other physician without our office's knowledge. I understand that it is unlawful to be prescribed the same controlled medication by more than one physician at a time without each physician's knowledge. I will take my medication as my prescription states and not alter it without my prescriber's knowledge.
2. All controlled medications must be obtained at the same pharmacy, where possible. Should the need arise to change pharmacies our office must be notified. The pharmacy that you have selected is:
Pharmacy
Phone
1. You may not share, sell or permit others to use your medications, including family members, spouses, friends, co-workers, etc.
2. Unannounced serum, oral swab or urine toxicology screens may be requested from you and your cooperation is required. Presence of unauthorized substances in such screens may result in discharge from this practice.
3. Medications may not be replaced if they are lost, stolen, get wet, are destroyed, left on vacation, etc. If your medication is stolen it will not be replaced without proof from authorities, including a police report.
4. Early refills will not be given. We request 5 business days for all prescription refills and that you keep all scheduled appointments. You may email or phone in your refill requests to our office.
5. I will not consume excessive amounts of alcohol with my medications. I will not use, purchase or obtain any other legal drugs without knowledge and approval from my prescriber. I will not use, purchase, sell or obtain any illegal drugs, including, cocaine, heroin, etc. I understand that driving while under the influence of any substance, including prescription medication, or any combination of substances (alcohol and controlled medications) which impairs my driving ability, may result in DUI charges.
6. I understand that failure to adhere to these guidelines may result in my medications not being refilled and furthermore, discharge from this practice.
Patient Name*
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Date*
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Electronic Consent*
By checking the "I Accept" box, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement. By selecting "I Accept" you consent to be legally bound by this agreement's terms and conditions.
- I Accept
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Medication & Controlled Substance Agreement (1)