Pain Treatment with Opioid Medications: Patient Agreement
This Agreement is essential to the trust and condence necessary in a prescriber/patient relationship. My prescriber has
discussed my treatment plan with me. I understand that there is a risk of psychological and/or physical dependence and
addiction associated with the chronic use of controlled substances for pain. I have been told about the side effects that I may
experience. My prescriber is undertaking to treat me with controlled substances for pain because:
I, __________________________________________ , understand and voluntarily agree to the following (initial each statement
after reviewing):
_____ I have told my prescriber about other medications I am taking and my medical history, including my prior experience
with pain medications or other drugs. Throughout my treatment, I will communicate fully with my prescriber
about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medication
is helping to relieve pain.
_____ I will take my medication, ___________________ , as instructed and not change the way I take it without rst talking
to my prescriber or other members of the treatment team. I understand that my prescriber may change this medication
during my course of treatment.
_____ I will not attempt to obtain pain medications from any other prescribers and understand that my prescriptions
will be issued only during scheduled ofce visits with the treatment team or during regular ofce hours. If I require
surgery or emergency treatment, and I am able to communicate, I will tell the health care professional taking care
of me about all the medications I am taking and, at or before my next rell, I will tell my prescriber about my use of
medications in these circumstances.
_____ I agree not to use illegal drugs or alcohol while on these medications.
_____ I understand that I should not drive a motor vehicle or operate machinery if the medication causes dizziness,
drowsiness, or sedation.
_____ I will use one pharmacy to get all my medications: _______________________________________________
Pharmacy Name/Phone Number
_____ I understand that I may be referred to other health care professionals for other modes of treatment, such as physical
therapy, exercise, relaxation techniques or psychological counseling, or for certain diagnostic tests and that
my prescriber may speak with other health care professionals about my treatment plan. At this time my treatment
plan includes: _________________________________________.
_____ I will keep the medicine safe, secure, and out of reach of others, and will dispose of unused medications in a
Project Medicine Drop Box, through a Take-back Program or in a drug disposal pouch.
_____ I will not sell this medicine or share it with others. If my medicine or prescription is lost or stolen, I understand that it
may not be replaced.
_____ I understand that I may need to submit to random urine drug testing and pill counts if requested by my prescriber
and that my prescriber will be verifying that I am receiving controlled substances from only one prescriber and
only one pharmacy by checking the Prescription Monitoring Program web site.
_____ I understand that if I do not follow all of the terms of this Agreement, my prescriber may stop prescribing pain
medications, and/or that I could be required to nd another prescriber or health care professional for my future
medical treatment.
______________________________________ __________________________________ __________________
Patient Signature Patient Name Printed Date
______________________________________ __________________________________ __________________
Prescriber Signature Prescriber Name Printed Date
NOTE: Some agreements include the actual side effects that a patient may experience. Other provisions may be included, but
are not required, such as:
_____ I will keep all of my scheduled appointments including appointments for rells. If I am having trouble making an
appointment, I will tell a member of the treatment team immediately.
_____ I will not call between appointments, or at night or on the weekends looking for rells. I understand that prescriptions
will be lled only during scheduled ofce visits with the treatment team or during regular ofce hours.
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