Buprenorphine Treatment AgreementBuprenorphine Treatment Agreement • September 14th, 2021
This form is for educational/informational purposes only. It doesn’t establish a legal or medical standard of care. Healthcare professionals should use their judgment in interpreting this form and applying it in the circumstances of their individual patients and practice arrangements. The information provided in this form is provided “as is” with no guarantee as to its accuracy or completeness.
Buprenorphine Treatment AgreementBuprenorphine Treatment Agreement • January 7th, 2024
BUPRENORPHINE TREATMENT AGREEMENTBuprenorphine Treatment Agreement • June 10th, 2021
Buprenorphine Treatment AgreementBuprenorphine Treatment Agreement • June 28th, 2018
As a participant in buprenorphine treatment for opioid addiction, I freely and voluntarily agree and understand this treatment agreement, in its entirety, as follows:
BUPRENORPHINE TREATMENT AGREEMENTBuprenorphine Treatment Agreement • January 27th, 2022
BUPRENORPHINE TREATMENT AGREEMENT/CONTRACTBuprenorphine Treatment Agreement • February 17th, 2015
• I agree not to arrive at the office intoxicated or under the influence of drugs. If I do, the doctor will not see me, and I will not be given any medication until my next scheduled appointment.
BUPRENORPHINE TREATMENT AGREEMENTBuprenorphine Treatment Agreement • March 7th, 2022
• I understand that buprenorphine/naloxone (Suboxone) is a medication to treat opiate addiction (heroin, oxycodone, hydrocodone, methadone). I am aware that taking Suboxone regularly can lead to physical dependence, and If I were to abruptly stop taking it after regular use, I could experience symptoms of opiate withdrawal.
Buprenorphine Treatment AgreementBuprenorphine Treatment Agreement • December 7th, 2017
ALTANTA MEDICAL ARTS AND WELLNESS, LLCBuprenorphine Treatment Agreement • March 10th, 2021
As a participant in the buprenorphine protocol for treatment of opioid abuse and dependence, I freely and voluntarily agree to accept this treatment agreement, as follows:
Buprenorphine Treatment Agreement/ContractBuprenorphine Treatment Agreement • June 26th, 2017
As a participant in buprenorphine treatment for opioid use disorders, I accept this treatment agreement/contract as follows:
BUPRENORPHINE TREATMENT AGREEMENTBuprenorphine Treatment Agreement • July 18th, 2023
Buprenorphine is a medicine that is used to treat opioid use disorder. Buprenorphine is a controlled substance and therefore the Controlled Substance Agreement also applies. Buprenorphine is an opioid which can help support recovery because it reduces craving and withdrawal symptoms and blocks the effects of stronger and more dangerous opioids. Buprenorphine is taken as a daily under the tongue film/pill, or it can be taken by monthly shot. This consent form is for the daily film or pill.
BUPRENORPHINE TREATMENT AGREEMENTBuprenorphine Treatment Agreement • September 25th, 2012
Buprenorphine Treatment AgreementBuprenorphine Treatment Agreement • July 1st, 2022
Buprenorphine Treatment AgreementBuprenorphine Treatment Agreement • October 4th, 2023
Buprenorphine is a potent medication and dangerous when a person does not have a tolerance for opioids. When a person takes buprenorphine without taking opiates or buprenorphine regularly, death may be a result. Risk, including death, may occur from combining buprenorphine with alcohol and other drugs like opiates and benzodiazepines (such as Valium, Klonopin, Ativan, Xanax). There is no fixed time for being on buprenorphine and that the goal of treatment is for to stop using all illicit drugs and become successful in all aspects of my life.
Buprenorphine Treatment AgreementBuprenorphine Treatment Agreement • April 8th, 2020
BUPRENORPHINE TREATMENT AGREEMENTBuprenorphine Treatment Agreement • March 15th, 2021
I, as a participant in buprenorphine treatment at Link House Center for Behavioral Health & Addiction Treatment Services understand and voluntarily agree that (initial each after reviewing):
Hennepin County Adult Detention Center Buprenorphine AgreementBuprenorphine Treatment Agreement • October 24th, 2019
Buprenorphine Treatment AgreementBuprenorphine Treatment Agreement • February 12th, 2019
(This is an example Patient Consent Form for medication assisted treatment with buprenorphine/Suboxone. Adapt any aspect of this policy to fit your clinic’s needs and specific protocols for office-based treatment of opioid use disorder.)
Buprenorphine Treatment AgreementBuprenorphine Treatment Agreement • October 9th, 2018
This form is for educational/informational purposes only. It doesn’t establish a legal or medical standard of care. Healthcare professionals should use their judgment in interpreting this form and applying it in the circumstances of their individual patients and practice arrangements. The information provided in this form is provided “as is” with no guarantee as to its accuracy or completeness.
