Narcotic Medication Agreement & Consent Form
You have agreed to receive narcotics for the treatment of your pain from Dr. F. Abbasi, (“Pain Physician�?). It is important that you have an understanding of the risks and your responsibilities that go along with this treatment. Please read and initial each statement tosignify your understanding.If you have any questions regarding this information or our policy regarding the prescribing of narcotics, please request clarification.
I, understand that:
CONSENT FOR TREATMENT: I voluntarily consent to the rendering of care, including treatments, administration of anesthetics and performance of diagnostic and/or surgical procedures. I understand that I am under the care and supervision of the attending Pain Physician and it is responsibility of the staff to carry out the instructions of Pain Physician.
RELEASE OF INFORMATION:The Physician may disclose all or part of the patient’s record to any person or corporation which is or may be liable under a contract to the physician or to the patient or to the Health Care Financing Administration and/or the patient’s attorney, for all or part of the physician’s charges, including but not limited to, patient insurance companies, worker’s compensation carriers, welfare funds, or the patient’s employer if a worker’s compensation case.
INITIAL ON EACH LINE BELOW:
Any medical treatment is initially a trial and that continued prescription of narcotics is based on evidence of benefit. I understand that the goal of using narcotics is to increase my functional level and decrease my pain. If these goals are not achieved, the medication will be stopped.
I am aware that the use of such medicine has certain risks associated with it, including, but not limited to: Sleepiness or drowsiness, constipation, nausea, itching, vomiting, lightheadedness, dizziness, confusion, allergic reaction, slowing of breathing rate, slowing of reflexes or reaction time, kidney or liver disease, sexual dysfunction, physical or psychological dependence, tolerance to the pain relieving effects, addiction, withdrawal, and the possibility that the medicine will not provide complete relief.
The overuse or misuse of narcotic medication can result in serious health risks including respiratory depression (stopping of breathing) or even death.
This medication will be strictly monitored and my medications should be filled at the same pharmacy. Should the need arise to change pharmacies, our office mustbe informed. The pharmacy name and the location of the pharmacy that I have selected is:
I cannot receive medication by phone, nor may I call the office to have a prescription called in. Early refill requests will not be honored.
I am responsible for making & keeping schedule appointments. I also understand that it may take up to 2 weeks to make a regular follow up appointment
I will take the narcotics medication only as prescribed. Any change must first be discussed and agreed upon with my Pain Physician
I agree that only my Pain Physician will prescribe narcotic medication. I will notobtain or use narcotic or other controlled substances from any other sources. I will instruct my other physicians to confer with Pain Physician for any changes or need for additional narcotics medication. If it is brought to the attention of the clinic that other providers are prescribing medications for me, Pain Physician reserve the right to discontinue prescribing medications and/or discharge me from clinic.
Narcotic Medication Agreement (Continued)
will inform my Pain Physician of any changes in my medical condition, any changes in anyprescription and/or over the counter medication (including herbals and supplements) that I take and of any adverse effect that I may experience from any of the medications that I take.
I agree to tell my Pain Physician my complete personal drug/medication usage and history.
I will not use any illegal “street drugs�? or alcohol while receiving medications from my Pain Physician. Examples include, but are not limited marijuana, cocaine, & amphetamines (“speed�?).
I will communicate fully and honestly with my Pain Physician 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.
Routine blood work and periodic drug screens may be a part of my treatment plan. I agree to have them done when my physician requests it.
The prescribing physician has my permission to discuss all diagnostic and treatment details to obtain prescription history with dispensing pharmacies, my insurance company, pharmacy benefits companies, or other professionals who provide my health care for the purpose of maintain accountability.
It is a felony to obtain narcotic under false pretenses. This could include getting medication from more than one doctor, misrepresenting myself to obtain medication, using them in a manner other than prescribed, or diverting the medications in any other way (i.e. selling).
I know that narcotic medication will be stopped if any of the following occur:
- I trade, sell , or misuse the medication
- The clinic find that I have broken anypart of this agreement
- I do not go for a blood or urine test immediately when asked to.
- My blood or urine test shows the presence of any illegal drugs.
- My blood or urine test shows the presence or absence of unexpected or expected medications.
- I get narcotics from sources other than mentioned Pain Physician
- Any member of the professional staff of this clinic feels that it is in my best interest that narcotic treatment be stopped.
- Any aggressive or inappropriate behavior towards physicians or staff.
- I consistently missed scheduled appointments.
It is understood that failure to adhere to this agreement may result in cancelation of therapy including prescribing of controlled substances by the Pain Physician.
I have read the Narcotic Medication Agreement and without question understand all of this agreement. By signing this agreement I affirm that I have read, understand, and accept the terms of this agreement.