Controlled Substance AgreementControlled Substance Agreement • June 8th, 2023
Controlled Substance AgreementControlled Substance Agreement • November 15th, 2022
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • September 17th, 2020
This agreement relates to my use of controlled substances for chronic pain prescribed by a provider at Valley Pain Specialists, P.C. I have been informed and understand the policies regarding the use of controlled substances that are followed by the staff at Valley Pain Specialists. I understand that I will be provided controlled substances while actively participating in this program only if I adhere to the following conditions:
Controlled Substance Agreement (Pain Contract)Controlled Substance Agreement • June 9th, 2016
DENVER BACK PAIN SPECIALISTS CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • May 21st, 2021
Controlled Substance Agreement / UnderstandingControlled Substance Agreement • November 8th, 2019
We are committed to doing all we can to treat your chronic pain condition. In some cases, controlled substances are used as a therapeutic option in the management of chronic pain and related anxiety and depression, which is strictly regulated by both state and federal agencies. This agreement is a tool to protect both you and the physician by establishing guidelines, within the laws, for proper controlled substance use. The words “we” and “our” refer to the facility and the words “I”, “you”, “your”, “me”, or “my” refer to you, the patient.
CONTROLLED SUBSTANCE (NARCOTIC) AGREEMENTControlled Substance Agreement • 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 AGREEMENTControlled Substance Agreement • February 3rd, 2022
Pain management may take the form of different criterion and is dependent upon each patient’s individual needs. On occasion after a thorough review of the patient’s medical history, failure of conservative, medical and surgical management, it may be determined that the patient requires controlled substances (narcotic medication) for effective pain management.
DENVER BACK PAIN SPECIALISTS CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • February 25th, 2013
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • April 29th, 2010
This agreement relates to my use of controlled substances for chronic pain prescribed by a provider at Valley Pain Specialists, P.C. I have been informed and understand the policies regarding the use of controlled substances that are followed by the staff at Valley Pain Specialists. I understand that I will be provided controlled substances while actively participating in this program only if I adhere to the following conditions:
CONTROLLED SUBSTANCE AGREEMENT You must agree to each of the following statements before we will prescribe a controlled medication to you:I am aware controlled medications are prescribed for many reasons, such as to relieve severe pain, relax muscles,...Controlled Substance Agreement • November 21st, 2021
Controlled Substance AgreementControlled Substance Agreement • May 5th, 2022
The purpose of this agreement is to outline the conditions under which my provider at Golden Victory Medical will prescribe controlled substances. By signing this form, I acknowledge I have been informed that individuals who are prescribed certain controlled substances including, but not limited to, narcotic pain medicines, stimulants, benzodiazepines, 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, it is necessary to observe strict rules pertaining to their use, and I agree to follow the terms and procedures described in this contract for my provider to consider prescribing or to continue prescribing controlled substances to treat my condition.
Controlled Substance AgreementControlled Substance Agreement • January 13th, 2017
am receiving controlled substances to treat chronic pain and its associated conditions. The purpose of this agreement is to protect my access to controlled substances for the treatment of my pain.
Controlled Substance AgreementControlled Substance Agreement • October 22nd, 2020
This agreement is about using controlled substances for chronic pain prescribed by Dr. Barrett Johnston at Interventional Pain Institute.
AGREEMENT FOR USE OF A CONTROLLED SUBSTANCEControlled Substance Agreement • July 30th, 2015
Edison, NJ 08820-2073Controlled Substance Agreement • August 4th, 2009
Controlled Substance AgreementControlled Substance Agreement • November 15th, 2022
Controlled Substance AgreementControlled Substance Agreement • August 20th, 2021
All patients for whom we prescribe any controlled substances (narcotics, sedatives, certain hormones, etc) are subject to in- office random drug testing.
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • July 18th, 2023
This agreement will help you and your Link House CBHATS medication prescriber ensure that you receive the best treatment possible, especially by concerning your prescribed controlled substances.
Controlled Substance AgreementControlled Substance Agreement • April 3rd, 2015
is a primary care facility offering the full-spectrum of Family Medicine. All patients presenting to may receive preventive health services and treatment of chronic medical conditions. We utilize controlled substances for treatment of our established clinic patients within the typical scope of Family Medicine.
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • June 26th, 2009
Controlled Substance AgreementControlled Substance Agreement • October 25th, 2017
Purpose: Pain Doctor requires all patients to provide a urine drug screen and sign a Controlled Substances Agreement before being prescribed any controlled substance medication. This protocol explains the process for this agreement.
AGREEMENT FOR LONG TERM CONTROLLED SUBSTANCE PRESCRIPTIONSControlled Substance Agreement • March 8th, 2022
Controlled Substance AgreementControlled Substance Agreement • April 7th, 2021
The following agreement relates to my use of controlled substances prescribed by my practitioner. I recognize that there are policies regarding the use of controlled substances that are following by the staff. I will be provided controlled substances while actively participating in this program only if I adhere to the following regulations:
Controlled Substance AgreementControlled Substance Agreement • May 5th, 2022
The purpose of this agreement is to outline the conditions under which my provider at Golden Victory Medical will prescribe controlled substances. By signing this form, I acknowledge I have been informed that individuals who are prescribed certain controlled substances including, but not limited to, narcotic pain medicines, stimulants, benzodiazepines, 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, it is necessary to observe strict rules pertaining to their use, and I agree to follow the terms and procedures described in this contract for my provider to consider prescribing or to continue prescribing controlled substances to treat my condition.
Controlled Substance AgreementControlled Substance Agreement • October 2nd, 2018
This agreement is to establish goals for treatment with opioids so that we can balance pain management with safety concerns. The goals of this treatment are to improve your quality of life and ability to function in your daily activities. If these goals are not met, or if the side effects outweigh the benefits, my clinician will stop this treatment and look for alternatives.
Controlled Substance Agreement FormControlled Substance Agreement • August 26th, 2020
I, , understand that in order to receive care for the treatment of pain or the use of controlled medications, I agree to and will comply with the following: (Initial that you have read each section)
Controlled Substance AgreementControlled Substance Agreement • November 12th, 2019
As part of your treatment plan, your physician has recommended use of controlled medications. These medications can be very beneficial in treating certain diagnoses and disorders. However, because of the potential risks of abuse/misuse of these controlled medications, they must be treated in a manner different than other prescription medications. It is your responsibility to read this agreement, and to ask any questions about any sections that you do not completely understand.
ContractControlled Substance Agreement • July 3rd, 2018
The American Recovery and Reinvestment Act of 2009 requires that we gather additional information from you about your background. Thank you for answering the following three questions: 1. Race ☐ American Indian or Alaskan Native ☐ Asian☐ Unknown ☐ Black, African American ☐ White☐ Declined ☐ Native Hawaiian, Other Pacific Islander☐ Hispanic or Latino 2. Ethnicity ☐ Hispanic or Latino☐ Declined ☐ Non Hispanic or Non Latino☐ Unknown 3. Primary Language ☐ English ☐ Spanish ☐ Other
CONTROLLED SUBSTANCE AGREEMENTControlled Substance Agreement • August 22nd, 2017
This agreement relates to my use of controlled substances for chronic pain prescribed by a provider at Valley Pain Specialists, P.C. I have been informed and understand the policies regarding the use of controlled substances that are followed by the staff at Valley Pain Specialists. I understand that I will be provided controlled substances while actively participating in this program only if I adhere to the following conditions:
In association with Controlled Substance AgreementControlled Substance Agreement • June 24th, 2014
Controlled Substance Agreement Sajad Zalzala, MDControlled Substance Agreement • July 15th, 2013
Dr. S. Zalzala, Provincial Pharmacy and staff are committed to doing all we can to treat your health conditions. In some cases, controlled substances are used as a therapeutic option for many chronic disorders. Controlled Substances are regulated by various government agencies. This agreement is a tool to protect both you the patient and the physician by establishing guidelines, within the laws, for proper and controlled substance use. The words “we” and “our” refer to the facility and the words “I,” “you,” “me,” or “my” refer to you, the patient.
CONTROLLED SUBSTANCE AGREEMENT USING PRESCRIPTION OPIOIDS AND OTHER CONTROLLED SUBSTANCESControlled Substance Agreement • December 18th, 2013
CONTROLLED SUBSTANCE AGREEMENT AND INFORMED COSENT FORMControlled Substance Agreement • March 19th, 2013
In May of 2011Governor Nathan Deal signed into law SB36, the Patient Safety Act of 2011, making Georgia one of the last states in the nation to provide legislation for the implementation of a prescription drug monitoring program (PDMP) to combat the growing problem of prescription drug abuse. As a result of this legislation and in the interest of promoting patient safety, the Georgia Composite Medical Board issued updated pain management minimum standards of practice (Rule 360.3.60) which require physicians to monitor patients to avoid narcotic dependency and addiction. A violation of these rules could subject the physician to sanctions and, more importantly, put patients at risk. The goal is to educate patients about the risks of long term narcotic use and reduce prescription drug abuse.
Controlled Substance AgreementControlled Substance Agreement • August 7th, 2024
The purpose of this Agreement is to prevent misunderstandings about certain medications that may be prescribed by this clinic.
