Patient Consent to Receive a Controlled Substance

This agreement will be the basis for receiving prescription(s) for any controlled substance. Failure on your part to strictly abide by the following requirements may result in the loss of privilege of being given a prescription for any controlled substance. It is the goal of the practice to reduce or eliminate the cause of your pain. Pain comes from several sources: structural problems in the spine, spasm, nerve inflammation, and/ or joint inflammation. More than one type of treatment and more than one type of medication is required to treat each of these sources.

You must read each of the following items carefully, then your signature will be required to show that you have read and understand each provision. If you have any questions, ask for an explanation before signing.
  • The decisions made by the provider will not be influenced by any type or amount of medication that you may have taken in the past.
  • I will take medications at the dose and frequency prescribed.
  • I will not increase or change how I take my medications without the approval of this health care provider.
  • I will arrange for refills for these medications only at pharmacy, phone number
  • I will bring the prescription bottles of the medication I receive from this office to every appointment for the remaining pills to be subject to count.
  • I will not request any pain medications or controlled substances from other providers, and I will inform this provider of all the medications I am taking.
  • I will inform my other health care providers that I am taking these pain medications and of the existence of this contract. In the event of an emergency, I will provide the same to the emergency department providers.
  • I will protect my prescriptions and medications. I understand that if lost, stolen or misplaced my prescriptions will not be replaced.
  • Patient will be required to comply to Urine Drug Screen (at the providers discretion) and follow up appointment requirements set by their provider.
  • I understand that if I am a woman of childbearing age and receiving a controlled substance, I should use an effective form of birth control and will inform my prescribing physician if I decide to try to become or do become pregnant.
  • I understand that my provider may choose to terminate our relationship, discontinue prescribing controlled substances to me and/or refer me to pain management in the event of an abnormal drug screen.
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