CONTROLLED SUBSTANCE THERAPY PATIENT-PHYSICIAN AGREEMENTControlled Substance • March 1st, 2021
The purpose of this agreement is to give you information about the controlled medications you will be taking for your medical condition(s) requiring prescription of such and to assure that you and your physician comply with all state and federal regulations concerning the prescribing of controlled substances. Our goal is to provide you with the best quality treatment of your medical condition. To accomplish this goal, your physician will customize your treatment plan to best fit your healthcare needs. Your treatment plan may include, but is not limited to, injection therapy, physical therapy, medication therapy, psychological counseling, relaxation therapy, exercise, and weight loss programs. When controlled substances are the best option, it is important to review and follow the policies to ensure your safety and our continued ability to treat you in the most effective way possible.
CONTROLLED SUBSTANCE PATIENT-‐PHYSICIAN AGREEMENT (PPA)Controlled Substance • April 27th, 2016
• To routinely check the state Prescription Monitoring Program, to see the medicines that you are getting from me and others.
CONTROLLED SUBSTANCE (NARCOTIC) AGREEMENTControlled Substance • November 17th, 2020
The purpose of this consent is to protect your access to controlled substances and to protect our ability to prescribe for you. The long-term use of such substances as opiates (narcotic analgesics), benzodiazepine, tranquilizers, and other sedatives are controversial because of uncertainty regarding the extent to which they provide long- term benefit. There is also the risk of an addictive disorder (psychological dependence/physical dependence) developing or of relapse occurring in a person with a prior addiction. The percent of this risk is not certain. Because these drugs have the potential for abuse or diversion, strict accountability is necessary when use is prolonged. For this reason the following policies are agreed to by you, the patient, as consideration for, any condition, the willingness of the physician and/or physician assistant whose signature appears below to consider the initial and/or continued prescription of controlled substances to treat your chronic pain.
CONTROLLED SUBSTANCE (NARCOTIC) AGREEMENTControlled Substance • March 24th, 2013
The purpose of this consent form is to protect your access to controlled substances and to protect our ability to prescribe for you.
CONTROLLED SUBSTANCE (NARCOTIC) AGREEMENTControlled Substance • February 8th, 2019
The successful management of chronic pain involves many modalities including, but not limited to, physical therapy (PT), surgical consultation, injection therapy, behavioral counseling and oral medications.
