Common Contracts
2 similar Treatment Agreement contracts
Agreement for Treatment with Buprenorphine/NaloxoneTreatment Agreement β’ October 15th, 2014
π Yes π No I understand that buprenorphine/naloxone is a medication to treat opiate addiction (for example: heroin, prescription opiates such as oxycodone, hydrocodone, methadone). Buprenorphine/naloxone contains the opiate narcotic analgesic medication, buprenorphine, and the opiate antagonist drug, naloxone, in a 4 to1 (buprenorphine to naloxone) ratio. The naloxone is present in the tablet to prevent diversion to injected abuse of this medication. Injection of buprenorphine/naloxone by a person who is addicted to opiateswill produce severe opiate withdrawal. π Yes π No 1. I agree to keep appointments and let staff know if I will be unable to show up asscheduled π Yes π No 2. I agree to report my history and my symptoms honestly to my physician, nurses, and counselors involved in my care. I also agree to inform staff of all other physicians and dentists who I am seeing; of all prescription and non- prescription drugs I am taking; of any alcohol or street drugs I have recentlybe
Agreement for Treatment with Buprenorphine/NaloxoneTreatment Agreement β’ October 15th, 2014
π Yes π No I understand that buprenorphine/naloxone is a medication to treat opiate addiction (for example: heroin, prescription opiates such as oxycodone, hydrocodone, methadone). Buprenorphine/naloxone contains the opiate narcotic analgesic medication, buprenorphine, and the opiate antagonist drug, naloxone, in a 4 to1 (buprenorphine to naloxone) ratio. The naloxone is present in the tablet to prevent diversion to injected abuse of this medication. Injection of buprenorphine/naloxone by a person who is addicted to opiateswill produce severe opiate withdrawal. π Yes π No 1. I agree to keep appointments and let staff know if I will be unable to show up asscheduled π Yes π No 2. I agree to report my history and my symptoms honestly to my physician, nurses, and counselors involved in my care. I also agree to inform staff of all other physicians and dentists who I am seeing; of all prescription and non- prescription drugs I am taking; of any alcohol or street drugs I have recentlybe
