Prescribed Treatment Agreement Sample Contracts
Prescribed Treatment AgreementPrescribed Treatment Agreement • July 13th, 2015
Client Name Client Date ofBirth / / Client Photograph Client Address Client Contact Number This photograph is for confirming the identity of the client in the pharmacy for drug treatment only. It may not be shared with any parties outside this agreement, copied or used for any other purposes. AddactionRecovery Worker Name AddactionContact Number Addaction Address Prescriber Name PrescriberContact Number Prescriber Address Shared Care?(Please Circle) Y / N Community Pharmacy Name & Address
Prescribed Treatment AgreementPrescribed Treatment Agreement • July 13th, 2015
Client Name Client Date of Birth / / Client Photograph Client Address Client Contact Number This photograph is for confirming the identity of the client in the pharmacy and RISE. It may not be shared with any parties outside this agreement, copied or used for any other purposes. RISERecovery Worker Name RISEContact Number RISEAddress Prescriber Name Prescriber Contact Number Prescriber Address Community Pharmacy Name &Address