- Abusive, unprofessional, uncontrolled behavior results in AUTOMATIC DISMISSAL from the practice.
- Our pain management clinic is a LOW DOSE NARCOTIC clinic with use of all other adjunctive pain management methods.
- I understand that there is a risk of psychological and/or physical dependence and addiction associated with chronic use of controlled substances.
- I understand that this Agreement is essential to the trust and confidence necessary in a provider/patient relationship and that my provider undertakes to treat me based on this Agreement.
- I agree that I will submit to a drug screen if requested by my provider to determine my compliance with my program of pain control medications.
- I will communicate fully with my provider about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain.
- I will provide my provider with updates on medications that are prescribed to me by any other provider, including primary care medications (blood pressure, asthma, diabetic, ADD/ADHD, seizure and psychiatric medications, etc.).
- I will not use any illegal controlled substances, including marijuana, cocaine, etc., nor will I misuse or self-prescribe/medicate with legal controlled substances. Use of alcohol will be limited to times when I am not driving or operating machinery and will be infrequent.
- I will not share my medication with anyone, nor will I take/use any controlled opioid medications that NOT prescribed to me.
- I will not attempt to obtain any controlled medications, including opioid pain medications, controlled stimulants, or anti-anxiety medications from ANY OTHER PROVIDER.
- I agree that I will use my medicine at a rate no greater than the prescribed rate and that use of my medicine at a greater rate will result in my being WITHOUT MEDICATION FOR A PERIOD OF TIME. NO EARLY REFILLS.
- I will safeguard my pain medication from loss, theft, or unintentional use by others, including youth. LOST OR STOLEN MEDICATIONS WILL NOT BE REPLACED.
- I agree to properly dispose of old, unused or discontinued medications. If a medication is discontinued for any reason, I WILL NOT continue to take that medication at the risk of interactions or overdose.
- I understand that my provider will be verifying that I am receiving controlled substances from only one prescriber and only one pharmacy by checking the Prescription Drug Monitoring Program web site periodically throughout my treatment period.
- I understand that refills for pain medications will be made ONLY at the time of an office visit or script refill visit. NO EARLY REFILLS. We DO NOT refill pain medication or prescribe new pain medication over the phone. You must have an appointment.
- In an effort to ensure you receive the best possible care, all medication will now be processed and filled by Cordant Pharmacy Solutions, a Denver, CO based pharmacy that delivers medications to patients. We also need to limit the amount of pharmacies per patient. For emergency purposes, you will be asked to choose a local pharmacy.
- I understand that I AM ULTIMATELY RESPONSIBLE for scheduling my appointments PRIOR to my medication due dates. When scheduling my appointments, I need to take weather conditions, Cordant delivery time, and unforeseen/emergency situations into consideration. Special circumstances will be considered, however, not guaranteed.
- I understand that I need to fill my medication in entirety. If my pharmacy cannot fill the full quantity of my prescription, I will inform my provider to resolve this issue.
- I authorize the provider and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state’s Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medication.
- I authorize my provider to provide a copy of this Agreement to my pharmacy, primary care provider and local emergency room. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations.
- I understand that if I break this Agreement, my provider will STOP PRESCRIBING these pain control medicines.
- I agree to follow these guidelines that have been fully explained to me.