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1. I am responsible for my controlled substance medications. If the prescription or medication is lost, misplaced, or stolen, or if I use it up sooner that prescribed, I understand that it will not be replaced. I am aware that I must report stolen medications to the police.
2. I will not request nor accept, the controlled substance medication from any other physician, or individual while I am receiving such medication from my doctor at _________________. Besides being illegal to do so, it may endanger my health. The only exception is if it is prescribed while I am admitted in a hospital, or discussed with my _________________ physician.
3. Refills of controlled substance medication:
a) Will be made only during regular office hours, _____ am to ______ pm _________ through __________, in-person, once each month during a scheduled office visit. Refills will not be made at night, on holidays, or weekends.
b) Will not be made as an "emergency", such as on Friday afternoon because I suddenly realize I will "run out tomorrow". I must keep track of my medication and plan ahead. I will call at least 24 hours ahead if I need assistance with a controlled substance medication prescription.
c) Will not be made if I "run out early". I will not take any more medication than prescribed unless I speak with my doctor or nurse at the office first. If I overuse my medication I will go through withdrawal. Withdrawal is a severe "flu-like" illness caused by the sudden cessation of opoids.
4. I understand that if I violate any of the above conditions, my controlled substance prescriptions and/or treatments at _________________ may be ended immediately. If the violation involves obtaining controlled substances from another individual, as described above, I may also be reported to my primary physician, local medical facilities, and other authorities.
5. I will not take any "street" drugs. I understand that taking any non-prescribed drugs may be grounds for expulsion from _________________.
6. I understand that the main treatment goal is to improve my ability to function and/or work. In consideration of that goal, and that I am being given a potent medication to reach that goal. I agree to help myself by following better health habits, specifically involving exercise, weight control, and the use of tobacco and alcohol. I understand that only through following a healthier lifestyle can I hope to have the most successful outcome to my treatment.
7. I understand that if the treatment team feels that I am not taking my medications in the prescribed manner or the medications are not improving my ability to function then I will be weaned off the medications.
8. I have been fully informed by my doctor and his/her staff about the psychological dependence (addiction) of a controlled substance, which I understand is rare. I know that some persons may develop tolerance, which is needed to increase the dose of the medication to achieve the same effect of pain control, and I do know that I will become physically dependent on the medication. This will occur if I am on the medication for several weeks and when I stop the medications, I must do so slowly and under medical supervision of I may have withdrawal symptoms.
Signature: ____________ __________________
Print Name: ____________ __________________

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