Controlled Substances Agreement for:Controlled Substances Agreement • December 6th, 2023
This Controlled Substance Medication Agreement allows you and your physician to work together in good faith, and for you to understand the importance of these medications. A “controlled substance medication”, or CSM, is a drug or chemical that is government regulated because of its illegality for sale or use when not prescribed by a physician. In prescribing a CSM, we partner with you to create the best treatment plan for your improvement and management of pain. This requires cooperation, trust, and mutual respect. If you cannot agree to the following terms, we will be unable to prescribe controlled pain medication for you.
Controlled Substances Agreement and Informed ConsentControlled Substances Agreement • March 20th, 2013
The purpose of this Agreement is to prevent misunderstandings about certain medicines you may be taking for pain management. This is to help both you and your doctor to comply with the law regarding controlled pharmaceuticals.
CONTROLLED SUBSTANCES AGREEMENTControlled Substances Agreement • August 17th, 2020
As used in this Agreement, the words “We”, “Us” and “Our” refer to Redefine Healthcare as a medical practice entity and to its physicians, physicians’ assistants, and nurse practitioners individually.
Controlled Substances Agreement and Informed ConsentControlled Substances Agreement • September 13th, 2017
The purpose of this Agreement is to prevent misunderstandings about certain medicines you may be taking for pain management. This is to help both you and your physician to comply with the law regarding controlled pharmaceuticals.
CONTROLLED SUBSTANCES AGREEMENTControlled Substances Agreement • December 27th, 2017
This agreement is to give information about getting a prescription for controlled substances. Controlled substances are medications that are watched closely because they can be abused or cause addiction. They include pain medications called “opiates” as well as medicines that reduce anxiety (ex. Xanax), a variety of sleeping pills, and medicines for ADHD (Attention Deficit Hyperactivity Disorder). Controlled substances may be helpful for some medical problems. Since these medicines can be abused, there are rules to make sure that all laws are followed. The goal of this office is to give you the best quality of life while protecting you from dangerous effects of the medicines. Successful treatment depends on trusting each other and being honest. To get a prescription for a controlled substance, these rules must be followed.
CONTROLLED SUBSTANCES AGREEMENTControlled Substances Agreement • September 18th, 2018
Controlled substances agreementControlled Substances Agreement • June 3rd, 2017
following issues regarding the treatment of pain with opioids (i.e., morphine and or morphine- like drugs like percocet, vicodin, oxycodone, oxyontin and others and or the treatment with benzodiazepines (like valium, xanax, klonopin, diazepam, alprazolam, clonazepam)
ContractControlled Substances Agreement • April 17th, 2022
Controlled Substances AgreementControlled Substances Agreement • March 4th, 2010
The purpose of this Agreement is to enter a mutual agreement regarding certain medicines (controlled substances) you will be taking or could be taking in the future. Prescription of controlled substances is strictly monitored by state and federal law...Controlled Substances Agreement • February 5th, 2021
CONTROLLED SUBSTANCES AGREEMENTControlled Substances Agreement • April 8th, 2014
The purpose of this agreement is to protect your access to controlled substances and to protect our ability to prescribe for you.
CONTROLLED SUBSTANCES AGREEMENTControlled Substances Agreement • May 10th, 2022
AS a patient of Williamsville Psychiatry, I 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.
CONTROLLED SUBSTANCES AGREEMENTControlled Substances Agreement • October 21st, 2023
ContractControlled Substances Agreement • August 22nd, 2020
Controlled Substances AgreementControlled Substances Agreement • August 27th, 2014
Controlled substance medications (i.e. narcotics, tranquilizers, barbiturates, stimulants and hormones) are very useful, but have a high potential for misuse and are, therefore, closely controlled by local, state, and federal governments. As a patient of Balance Women’s Health, I agree to the following:
Information and Agreement Regarding Controlled SubstancesControlled Substances Agreement • March 13th, 2022
This agreement is a tool to protect both you and your 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 Substances AgreementControlled Substances Agreement • October 15th, 2018
This agreement is made to prevent any misunderstanding regarding your prescriptions for controlled substances and to comply with the laws governing controlled pharmaceuticals. Please read and initial each line below.
This agreement refers to medicines belonging to any of the following categories: Opiates, Opiate like (e.g., Tramadol), Benzodiazepines, Hypnotics and Stimulants.Controlled Substances Agreement • May 1st, 2023
___ The risks, benefits, alternatives, and side effects of my controlled substance medicines have been explained to me, and I understand the explanation.
24HR Lifeline MD CONTROLLED SUBSTANCES AGREEMENTControlled Substances Agreement • March 5th, 2024
The purpose of this agreement is to protect your access to controlled substances and to protect our ability to prescribe for you. Furthermore, this agreement is to prevent misunderstandings about certain medicines the patient will be taking for pain management.
CONTROLLED SUBSTANCES AGREEMENTControlled Substances Agreement • November 18th, 2015
The main treatment goal for the management of chronic pain is to improve my ability to function and/or work. The goal is to improve my functional ability for as long as possible and to relieve my suffering. This usually involves many different kinds of treatments and medications that work together to decrease pain. My participation and involvement in this management plan is important for its success. As a patient at ACHN Clinic, I have certain rights and responsibilities, including the right to effective assessment and management of pain, and the responsibility to follow the agreed-upon treatment plan.
AGREEMENT FOR THE USE OF CONTROLLED SUBSTANCESControlled Substances Agreement • February 3rd, 2017
The chronic use of narcotic pain medications and other potentially addicting substance (e.g. stimulants for ADD & ADHD and sedatives for sleep or anxiety) are very useful in the treatment of many medical conditions that have failed other conventional therapies. These substances, however, are potentially dangerous and strictly regulated. The patient has obligations when using them. In order to provide you with the best medical care, we have established certain guidelines which we ask you to adhere to. These are primarily for your protection.
Agreement for Controlled SubstancesControlled Substances Agreement • April 23rd, 2020
Lifespan Behavioral Health Services PC Controlled Substances AgreementControlled Substances Agreement • May 11th, 2020
Please initial each line after reviewing, with your initials serving as your consent and understanding of each portion contained in this voluntary agreement.
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.
The purpose of this agreement is to explain what Optimae expects when patients are prescribed controlled medications, like stimulants (Adderall and Ritalin for example) and benzodiazepines (like Alprazolam, Clonazepam, and Temazepam). It is to help...Controlled Substances Agreement • February 22nd, 2022
