Common Contracts
1 similar Controlled Substances Agreement contracts
CONTROLLED SUBSTANCES AGREEMENTControlled Substances Agreement • July 25th, 2013
I, , a patient of Dr. [PHYSICIAN PRACTICE/PROVIDER], have been informed that individuals who are prescribed certain controlled substances including, but not limited to, narcotic pain medicines, stimulants, benzodiazepine tranquilizers, 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, I have been informed that it is necessary to observe strict rules pertaining to their use, and I agree to follow the terms and procedures described in this Agreement as consideration for, and as a condition of, the willingness of the physician whose signature appears below to consider prescribing or to continue prescribing controlled substances to treat my pain.
