Medication Use Agreement
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I, ____________________________, understand that I have pain that has not been adequately controlled with other medications and that my function is limited by my pain. I understand that the intent of the medication is to increase my ability to do more, though the medication is unlikely to eliminate the pain.
I will take the medication only as prescribed. I will not take any sedatives, alcohol or other pain medications without the prior approval of my doctor.
I understand that the medication will be prescribed only by Dr. ____________________________ and only according to the agreed-upon schedule. Prescriptions will be provided only during regularly scheduled appointments. Refills will never be provided by telephone.
I will not seek or accept any medications for pain other than those prescribed by my doctor. "Medications for pain" includes prescriptions from other doctors, medications borrowed or accepted from family or friends, and any illicit or street drugs.
Medication refills will be provided as written prescriptions only. No refills will be given prior to the next scheduled appointment date. If I do not keep my appointment, I will not receive a refill. Two (2) appointment cancellations with less than one working day's notice or two (2) no-show appointments may constitute grounds for immediate termination of this agreement.
I understand that my doctor is under no obligation to provide these medications to me, and that she or he reserves the right to discontinue these medications at any time. At my doctor's discretion, I agree to cooperate with random drug testing, which may be requested at any time. If I refuse, I understand the medication will be stopped.
I understand that lost or stolen medications will not be refilled under any circumstances. It is my responsibility to protect and secure any medications. This includes keeping the medication out of reach of children. A copy of a police report will be required for any lost or stolen narcotics or narcotic prescriptions.
I understand that my doctor may require specialist evaluation of my treatment, and I agree to keep appointments when my physician refers me. My doctor will send a report of my care and a copy of this agreement when a referral is made.
In addition to the above agreements, I accept the right of my doctor's medical staff to terminate this agreement for any of the following reasons:
1. I seek or obtain any pain medication from a source other than my doctor.
2. I give, sell or in any way distribute prescribed medications to any other person(s).
3. I in any way attempt to forge or alter a prescription.
4. My medical condition declines to the point at which, in the judgment of my doctor, continued therapy with this medication presents a danger to my well-being or safety.
5. There is evidence that I am no longer receiving a reasonable therapeutic benefit from the medication, or my doctor determines that I am no longer a good candidate to continue the medication.
I agree to fill my prescriptions only at the pharmacy I list below. If I change pharmacies, I will contact my doctor's office and provide them with the name, address and phone number of the new pharmacy. Under no circumstances will I obtain medications from more than one pharmacy at a time. In order to verify appropriate medication use, my doctor's office will provide my chosen pharmacy with a copy of this agreement.
I understand that any alteration in my medication prescriptions will require a new written agreement.
Pharmacy name___________________________________________
Pharmacy address_________________________________________
_______________________________________________________
Pharmacy telephone________________________________________
Medication name, dose and directions __________________________
Number of pills prescribed _____Frequency of appointments _____days
I understand that by signing this agreement, I must abide by the rules reviewed above and that failure to abide by these agreements will result in the termination of medication prescriptions and possibly the termination of services from my doctor and his or her practice.
| __________________________ | ___/___/___ | __________________________ | ___/___/___ |
| Patient signature | Date | Physician signature | Date |
Developed by the Harpers Ferry Family Medicine Center. Copyright © 2001 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. "A Tool for Safely Treating Chronic Pain." Teichman PG. Family Practice Management. Nov/Dec 2001:47-49, www.aafp.org/fpm/20011100/47atoo.html.
