Controlled Substance AgreementControlled Substance Agreement • June 8th, 2023
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • September 17th, 2020
This agreement relates to my use of controlled substances for chronic pain prescribed by a provider at Valley Pain Specialists, P.C. I have been informed and understand the policies regarding the use of controlled substances that are followed by the staff at Valley Pain Specialists. I understand that I will be provided controlled substances while actively participating in this program only if I adhere to the following conditions:
Controlled Substance Agreement / UnderstandingControlled Substance Agreement • November 8th, 2019
We are committed to doing all we can to treat your chronic pain condition. In some cases, controlled substances are used as a therapeutic option in the management of chronic pain and related anxiety and depression, which is strictly regulated by both state and federal agencies. This agreement is a tool to protect both you and the physician by establishing guidelines, within the laws, for proper controlled substance use. The words “we” and “our” refer to the facility and the words “I”, “you”, “your”, “me”, or “my” refer to you, the patient.
Controlled Substance Agreement/Contract (Opioid Pain Medications)Controlled Substance Agreement • March 12th, 2010
This is an agreement between (the patient) and Dr. Robert Brown (the doctor) concerning the use of controlled Substances (opioid pain medications, benzodiazepines, stimulants, and other sedatives) for the treatment of a chronic pain problem.
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • September 26th, 2022
Pain management may take the form of different criterion and is dependent upon each patient’s individual needs. On occasion after a thorough review of the patient’s medical history, failure of conservative, medical and surgical management, it may be determined that the patient requires controlled substances (narcotic medication) for effective pain management.
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • April 29th, 2010
This agreement relates to my use of controlled substances for chronic pain prescribed by a provider at Valley Pain Specialists, P.C. I have been informed and understand the policies regarding the use of controlled substances that are followed by the staff at Valley Pain Specialists. I understand that I will be provided controlled substances while actively participating in this program only if I adhere to the following conditions:
Controlled Substance AgreementControlled Substance Agreement • May 5th, 2022
The purpose of this agreement is to outline the conditions under which my provider at Golden Victory Medical will prescribe controlled substances. By signing this form, I acknowledge I have been informed that individuals who are prescribed certain controlled substances including, but not limited to, narcotic pain medicines, stimulants, benzodiazepines, and barbiturate sedatives, can abuse those substances or may allow abuse by others, and have some risk of developing an addictive disorder or suffering a relapse of a prior addiction. Therefore, it is necessary to observe strict rules pertaining to their use, and I agree to follow the terms and procedures described in this contract for my provider to consider prescribing or to continue prescribing controlled substances to treat my condition.
Controlled Substance AgreementControlled Substance Agreement • January 13th, 2017
am receiving controlled substances to treat chronic pain and its associated conditions. The purpose of this agreement is to protect my access to controlled substances for the treatment of my pain.
Metropolitan Pain Management Consultants, Inc. A Medical Group Lee T. Snook, Jr., M.D., D.A.B.P.M., F.A.C.P., F.A.S.A.M. Medical Director PAIN MANAGEMENT/CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • September 17th, 2020
I, {patient_fname} {patient_lname}, 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 prescribed opioid (narcotic) medication to help me reach that goal. I agree to help myself by following better health habits, specifically involving exercise, weight control, and restricting the use of tobacco. I understand that other medical care may be prescribed to help improve my ability to perform activities of daily living and my ability to work. This may include exercise, use of non-narcotic analgesics, physical therapy, psychological counseling or other therapies or treatment. I understand that only through following a healthier lifestyle can I hope to have the most successful outcome to my treatment. I also understand that in order to receive care for the treatment of pain or the use of controlled medications, I agree to and will comply with the following:
Controlled Substance AgreementControlled Substance Agreement • October 22nd, 2020
This agreement is about using controlled substances for chronic pain prescribed by Dr. Barrett Johnston at Interventional Pain Institute.
Edison, NJ 08820-2073Controlled Substance Agreement • August 4th, 2009
PEDIATRIC CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • May 27th, 2021
The use of (print names of medication(s) is only one part of the treatment for: (print name of condition—e.g., ADD/ADHD, pain, anxiety, etc.) .
Controlled Substance AgreementControlled Substance Agreement • August 20th, 2021
All patients for whom we prescribe any controlled substances (narcotics, sedatives, certain hormones, etc) are subject to in- office random drug testing.
Controlled Substance AgreementControlled Substance Agreement • April 3rd, 2015
is a primary care facility offering the full-spectrum of Family Medicine. All patients presenting to may receive preventive health services and treatment of chronic medical conditions. We utilize controlled substances for treatment of our established clinic patients within the typical scope of Family Medicine.
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • June 26th, 2009
Controlled Substance AgreementControlled Substance Agreement • October 25th, 2017
Purpose: Pain Doctor requires all patients to provide a urine drug screen and sign a Controlled Substances Agreement before being prescribed any controlled substance medication. This protocol explains the process for this agreement.
Controlled Substance AgreementControlled Substance Agreement • April 7th, 2021
The following agreement relates to my use of controlled substances prescribed by my practitioner. I recognize that there are policies regarding the use of controlled substances that are following by the staff. I will be provided controlled substances while actively participating in this program only if I adhere to the following regulations:
Chronic Pain Medicine, Narcotic/Opioid & Controlled Substance AgreementControlled Substance Agreement • September 6th, 2011
Controlled Substance AgreementControlled Substance Agreement • May 5th, 2022
The purpose of this agreement is to outline the conditions under which my provider at Golden Victory Medical will prescribe controlled substances. By signing this form, I acknowledge I have been informed that individuals who are prescribed certain controlled substances including, but not limited to, narcotic pain medicines, stimulants, benzodiazepines, and barbiturate sedatives, can abuse those substances or may allow abuse by others, and have some risk of developing an addictive disorder or suffering a relapse of a prior addiction. Therefore, it is necessary to observe strict rules pertaining to their use, and I agree to follow the terms and procedures described in this contract for my provider to consider prescribing or to continue prescribing controlled substances to treat my condition.
Controlled Substance AgreementControlled Substance Agreement • October 2nd, 2018
This agreement is to establish goals for treatment with opioids so that we can balance pain management with safety concerns. The goals of this treatment are to improve your quality of life and ability to function in your daily activities. If these goals are not met, or if the side effects outweigh the benefits, my clinician will stop this treatment and look for alternatives.
Controlled Substance AgreementControlled Substance Agreement • November 12th, 2019
As part of your treatment plan, your physician has recommended use of controlled medications. These medications can be very beneficial in treating certain diagnoses and disorders. However, because of the potential risks of abuse/misuse of these controlled medications, they must be treated in a manner different than other prescription medications. It is your responsibility to read this agreement, and to ask any questions about any sections that you do not completely understand.
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • August 22nd, 2017
This agreement relates to my use of controlled substances for chronic pain prescribed by a provider at Valley Pain Specialists, P.C. I have been informed and understand the policies regarding the use of controlled substances that are followed by the staff at Valley Pain Specialists. I understand that I will be provided controlled substances while actively participating in this program only if I adhere to the following conditions:
Controlled Substance Agreement Sajad Zalzala, MDControlled Substance Agreement • July 15th, 2013
Dr. S. Zalzala, Provincial Pharmacy and staff are committed to doing all we can to treat your health conditions. In some cases, controlled substances are used as a therapeutic option for many chronic disorders. Controlled Substances are regulated by various government agencies. This agreement is a tool to protect both you the patient and the physician by establishing guidelines, within the laws, for proper and controlled substance use. The words “we” and “our” refer to the facility and the words “I,” “you,” “me,” or “my” refer to you, the patient.
CONTROLLED SUBSTANCE AGREEMENT USING PRESCRIPTION OPIOIDS AND OTHER CONTROLLED SUBSTANCESControlled Substance Agreement • December 18th, 2013
Cheney Psychiatric Associates, LLCControlled Substance Agreement • April 30th, 2020
_____ 1. I am aware that there are risks associated with controlled substances that include the potential for tolerance, dependence, and withdrawal upon abrupt discontinuation. I will take my medication only as prescribed, will not use other mood-altering substances, and will not take medications that are not prescribed to me.
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • May 16th, 2016
by the federal government, has higher risks than other medications, but is effective when used correctly and recommended by your provider.
Frisco Primary Care, P.A. Controlled Substance AgreementControlled Substance Agreement • December 22nd, 2020
The purpose of this Agreement is to prevent confusion about certain prescription medications that are controlled substances that you may be prescribed for pain or other illness management. This Agreement is to help both you and your doctor follow the state and federal laws on controlled substances. Controlled substances include medication such as narcotic pain relievers, stimulants, anxiety medications, ADHD / ADD medications, and sleeping medications. These medications are controlled and regulated by the Department of Public Safety based upon their medicinal value, harmfulness, and potential for abuse or addiction.
Controlled Substance AgreementControlled Substance Agreement • April 5th, 2023
Controlled Substance AgreementControlled Substance Agreement • February 2nd, 2016
The providers at Family Care Walk In Clinic understand the need for pain control for patients suffering from chronic pain. Ultimately, it is our goal to decrease pain and discomfort for each of our patients in a safe, effective manner. Below, is a contract intended to promote a mutual understanding between the provider and the patient regarding controlled medications for pain and other scheduled medications such as Adderall, Xanax, etc. Patients with prolonged (chronic) symptoms will have an individualized plan to improve symptoms which may include Physical Therapy, Psychological Assessment, Counseling, or a reduction and eventual cessation of narcotic use. The pain management plans are based upon clinical findings, the patient’s pain level and ultimately, the discretion of the providers. Generally, the providers at Family Care prescribe controlled substances on a short-term basis for acute problems and will not prescribe these medications for long term use.
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • April 9th, 2020
The purpose of this Agreement is to enter a mutual contract regarding certain medicines (controlled substances) you will be taking or could be taking in the future. Prescription of controlled substances is strictly monitored by state and federal law so strict accountability is necessary.
David Donahue, D.O.Controlled Substance Agreement • April 7th, 2024
The purpose of this contract is to establish an agreement between the clinician and patient on conditions for prescribing and use of controlled substances in the event use of these agents is deemed medically appropriate. This agreement is essential in maintaining the trust and confidence necessary in the clinician/patient relationship. Should controlled medication be a part of your treatment, the frequency and type of medication prescribed is, and must be, under the discretion of your prescribing clinician: David Donahue, D.O., David Fawks, APRN, Kristoffer Guerrero, APRN or Smitha Ajesh, APRN.
Controlled Substance AgreementControlled Substance Agreement • April 27th, 2020
● I will take all medications exactly as instructed by Dr. Harrison. I understand that I will not receive early refills under any circumstance. If my pain control is inadequate, I will schedule an appointment to discuss this with Dr. Harrison. Any unauthorized increase in the dose of narcotic medication(s) may be viewed as a cause for discontinuation of the treatment with controlled medication(s).
Controlled Substance AgreementControlled Substance Agreement • November 8th, 2022
My physician and I have a common treatment goal to improve my ability to function and/or work. In consideration of that goal, I am being treated with medications such as benzodiazepines or barbiturates. These medications may impair my alertness, reflexes, coordination and judgment. The use of these types of medications is controlled and monitored by local, state and federal agencies. These medications can be highly effective when taken as directed under medical supervision, but have the potential of abuse and misuse.
Controlled substance agreement pdfControlled Substance Agreement • October 19th, 2020
List all controlled substances that must be subject to the agreement (including agents such as Tramadol) which drugs fall under another contract (e.g. Benzodiazepines prescribed by a psychiatrist) Document all provisions (examples) All controlled substances in the contract must be prescribed by one supplier (with which the patient All controlled substances in the contract must be tracked down by one pharmacy of medicines refillsMust be made during a scheduled appointment (not by phone or within a few hours on call provider) Lost prescriptions should not include the date of the nearest refill plan Treatments should be made clear to the patient (including acute exacerbation of chronic pain) ComplianceUrine Drug Screening can be ordered Control substance monitoring program may be available broken controlled criteria of the contract substance Effects of broken controlled substance Contractcontracting provider will no longer prescribe controlled substances to the patient Other specialists C
INFORMED CONSENT CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • May 12th, 2021
The purpose of this agreement is to create an understanding regarding controlled substances that may benefit your chronic pain symptoms. My goal is to treat you safely with these potent medications and to prevent abuse of or addiction to these medications. Medications such as opioids, benzodiazepines, tranquilizers, barbiturate sedatives and muscle relaxants, that may be useful in managing pain, can be problematic in several ways. Many of the medications used have common side effects such as dizziness or drowsiness, dry mouth, constipation, nausea, itching, fatigue, vomiting, headache, insomnia, sweating, nervousness, confusion, falls, anxiety, edema/swelling, urinary retention, and sexual dysfunction. These medications have “street value” and potential for abuse. Although these medications may be prescribed with a goal of improving your comfort and functionality, their medical use is also associated with the risk of serious adverse
