Medication Agreement & Refill PolicyMedication Agreement • November 29th, 2023
As part of your treatment, our medical staff may prescribe medications for you. Many of these medications can have serious side effects if they are not managed properly. Your health and safety are very important to us, and we need your help to make sure your treatment follows our guidelines. If our medical staff at 1st Choice Healthcare, Inc. has any questions regarding your healthcare, including medications, we reserve the right to contact your other treating physicians and pharmacies.
Medication AgreementMedication Agreement • March 20th, 2019
This information is confidential and will be available only to relevant staff and emergency medical personnel. The agreement section must be completed by a medical practitioner (GP or specialist), nurse practitioner, or pharmacist. Authorisation/Release must be completed by the parent or legal guardian, or the adult student. The authorisation/release and agreement sections must be completed for the medication to be administered in an education or care setting. This is a single medication sheet; use a separate form for each medication. All sections of the form must be completed.Medication Agreements that are modified, overwritten or illegible will NOTbe accepted. UR / Client number:(if relevant) Name: Address: DOB: Fill in or attach the patient label
Self-Medication Agreement (Including Inhalers)Medication Agreement • January 11th, 2017
Students who are developmentally and/or behaviorally able, will be allowed to self-administer prescription and nonprescription medication, subject to the following:
GREATER ALBANY PUBLIC SCHOOLS SELF-MEDICATION AGREEMENTMedication Agreement • July 24th, 2020
Students who are developmentally and/or behaviorally able, will be allowed to self-administer medication, subject to the following:
Benzodiazepine Medication AgreementMedication Agreement • May 5th, 2023
This document is an agreement between patient and physician regarding the use of benzodiazepines, a class of controlled substance medications used to treat a variety of conditions including anxiety, insomnia, muscle spasticity, convulsive disorders, as well as detoxification from alcohol and other substances. This document establishes clear guidelines for the safe use of these medications. This agreement is intended for patients with an established or anticipated chronic use of a benzodiazepine medication, defined as 90 or more days of use in a 12- month period.
MEDICATION AGREEMENTMedication Agreement • September 6th, 2020
As part of your treatment, medications may be prescribed for you. These medications possibly could have serious side effects if they are not managed properly.
PRINT CLEARLY AND SIGN AT BOTTOM OF PAGEMedication Agreement • February 3rd, 2009
In order to provide medications to you as part of your pain management program, certain guidelines need to be followed to ensure your safety and maximum benefit from the medication. By signing this form, you are agreeing to follow all the information provided below, as well as the important facts provided by your physician.
Prescription Medication AgreementMedication Agreement • March 9th, 2020
While undergoing oral surgical treatment, you may be prescribed medication, such as Norco, Percocet, Valium, and others that could impair your ability to operate a motor vehicle, heavy machinery or other equipment.
Self-Medication Agreement for Prescription InhalersMedication Agreement • August 17th, 2018
Students who are developmentally and/or behaviorally able, will be allowed to self-administer prescription inhalers, subject to the following:
Self Carried / Self Administered Medication Agreement Sauk Centre Public Schools ISD #743Medication Agreement • May 27th, 2015
Medication is permitted in accordance with district policy and procedure(s). In addition to the parent/legal guardian, the student’s physician must authorize self-carried/administered medication. This can be provided by a written consent from the physician, or by validation on the medication container, inhaler or injector.
This Agreement sets out the rules for taking prescribed pain medicines and the rules for prescription refills.Medication Agreement • June 28th, 2016
MEDICATION AGREEMENTMedication Agreement • December 6th, 2016
Unless otherwise noted, the word “physician” or “physicians” as used herein shall mean and refer to Dr. Timothy D. Lucey and any physician employed by Timothy D. Lucey, DO., and PLLC.
Houghton Valley SchoolMedication Agreement • March 15th, 2017
Medical Condition Medicine to be administered Dosage State under what conditions medicine is to be taken Tick if you require the taking of this medication to be recorded
Medication AgreementMedication Agreement • September 12th, 2022
MEDICATION AGREEMENT & REFILL POLICYMedication Agreement • May 19th, 2016
As part of your treatment, our medical staff may prescribe medications for you. Many of these medications can have serious side effects if they are not managed properly. Your health and safety are very important to us, and we need your help to make sure your treatment follows our guidelines. If Nevada Advanced Pain Specialists has any questions regarding your healthcare, including medications, we reserve the right to contact your other treating Physicians, pharmacies, and hospitals.
Over-the-counter medication Agreement FormMedication Agreement • August 23rd, 2017
Over-the-counter medication (“OTC medication”) may at times need to be dispensed to a participant in the described program if approved by the participant’s parent or legal guardian. NOTE: The University of Tennessee will not dispense any OTC medication without the written authorization of a participant’s parent or legal guardian.
CENTRAL POINT SCHOOL DISTRICT 6 SELF-MEDICATION AGREEMENTMedication Agreement • October 23rd, 2023
Students who are developmentally and/or behaviorally able, will be allowed to self-administer medication, subject to the following:
Name:Medication Agreement • October 22nd, 2008
I, , agree to the following rules about my medicine(s). I am taking these medicines to treat: The medication(s) covered by this agreement include: Please PRINT clearly
Medication Agreement PolicyMedication Agreement • June 27th, 2016
The ministry of Education require that administration of all medication at a licensed facility be done so under the following standards.
SELF-MEDICATION AGREEMENTMedication Agreement • April 26th, 2018
Students, who are developmentally and/or behaviorally able, will be allowed to self-administer prescription and non-prescription medications, subject to the following. Certain medications, such as stimulants, narcotics and barbiturates are not allowed to be self-medicated.
MEDICATION AGREEMENTMedication Agreement • November 12th, 2017
The purpose of this agreement is to protect your proper use of controlled substances and to protect our ability to prescribe for you. Furthermore, this agreement is to assure a patient/physician relationship based on the need to serve and comply with the city, state and federal laws and regulations regarding the appropriate use of controlled pharmaceuticals. Associated risks of opioid (narcotic) medications include risk of an addictive disorder developing or of relapse with a prior addiction. Other potential risks may include: falls, sedation, osteoporosis, endocrine problems and others. The extent of these risks are not certain. Because these drugs have potential for abuse or diversion, strict accountability is necessary.
Self-‐Medication AgreementMedication Agreement • July 22nd, 2015
Students who are developmentally and/or behaviorally able will be allowed to self-administer prescription and nonprescription medication, subject to the following:
Annual Authorization from a Parent/ Legal Guardian and Healthcare Provider is REQUIRED for ALL MedicationMedication Agreement • August 6th, 2020
Self-Medication AgreementMedication Agreement • August 22nd, 2017
Students who are developmentally and/or behaviorally able will be allowed to self-administer those prescription and nonprescription medications allowed under district policy, subject to the following:
UNIVERSITY OF KENTUCKYMedication Agreement • November 4th, 2016
to our patients as part of an overall treatment plan in order to reduce pain to a tolerable level and improve their ability to perform daily activities. While these medications can be beneficial in managing your pain on a time limited basis, they are also controlled substances regulated by the DEA as well as Kentucky State Law and can have serious medical, legal and social consequences if used inappropriately. Use of controlled substances should be discontinued after the acute medical complaint is resolved.
NARCOTIC MEDICATION AGREEMENTMedication Agreement • December 2nd, 2014
You have agreed to receive narcotics for the treatment of your pain. It is important that you have an understanding of the risks and responsibilities that go along with this treatment. Please read each statement and sign this agreement/contract below. If you have any questions regarding this information or the office policy regarding the prescribing of narcotics, please request clarification.
Medication AgreementMedication Agreement • August 17th, 2023
The agreement section must be completed by a medical practitioner (GP or specialist), nurse practitioner, or pharmacist. Authorisation/Release must be completed by the parent or legal guardian, or the adult student.
Medication Agreement & Refill PolicyMedication Agreement • March 29th, 2017
As part of your treatment, our medical staff may prescribe medications for you. Many of these medications can have serious side effects if they are not managed properly. Your health and safety are very important to us, and we need your help to make sure your treatment follows our guidelines. If our medical staff at 1st Choice Healthcare, Inc. has any questions regarding your healthcare, including medications, we reserve the right to contact your other treating physicians and pharmacies.
Self-Medication Agreement (Including Inhalers)Medication Agreement • January 11th, 2017
Students who are developmentally and/or behaviorally able, will be allowed to self-administer prescription and nonprescription medication, subject to the following:
La Salle Catholic College PrepMedication Agreement • July 13th, 2022
Students who are developmentally and/or behaviorally able, will be allowed to self-administer medication, subject to the following:
Patient/Provider Controlled Medication AgreementMedication Agreement • January 15th, 2022
The purpose of this agreement is to be certain that long-term controlled substances are prescribed in the safest, most effective manner in compliance with current law. Utilization of controlled substances over a long period of time may be medically useful, but may carry the risk of dependency, addiction, and loss of effectiveness. You must understand and agree to the following terms in order for us to enter with into a prescribing relationship. I understand that breaking the terms of this agreement will mean my doctor will no longer prescribe controlled substances for my condition. I understand that violating the terms of this agreement could result in discharge from the practice. Please initial next to each number.
Medication AgreementMedication Agreement • May 14th, 2020
This information is confidential and will be available only to relevant staff and emergency medical personnel. The agreement section must be signed by a medical practitioner (GP or specialist), nurse practitioner, or pharmacist. Authorisation/Release must be signed by the parent or legal guardian, or the adult student. The authorisation/release and agreement sections must be signed for the medication to be administered in an education or care setting. This is a single medication sheet; use a separate form for each medication. All sections of the form must be completed.Medication Agreements that are modified, overwritten or illegible will NOTbe accepted. UR / Client number:(if relevant) Name: Address: DOB: Fill in or attach the patient label
UR / ClientMedication Agreement • June 24th, 2023
This information is confidential and will be available only to staff trained to manage seizures, those providing training to manage seizures, and emergency medical personnel.
The purpose of this agreement is to structure our plan to work together to treat your chronic pain. This will protect your access to controlled substances and our ability to prescribe them to you. By initialing the statements below, I acknowledge that...Medication Agreement • August 19th, 2013
Opioids have been prescribed to me on a trial basis. One of the goals of this treatment is to improve my ability to perform various functions, including return to work. If significant, demonstrable improvement in my functional capabilities does no result from this trial of treatment; my prescriber may determine to end the trial.
Medication AgreementMedication Agreement • February 22nd, 2019
This information is confidential and will be available only to relevant staff and emergency medical personnel. The agreement section must be completed by a medical practitioner (GP or specialist), nurse practitioner, or pharmacist. Authorisation/Release must be completed by the parent or legal guardian, or the adult student. The authorisation/release and agreement sections must be completed for the medication to be administered in an education or care setting. This is a single medication sheet; use a separate form for each medication. All sections of the form must be completed.Medication Agreements that are modified, overwritten or illegible will NOTbe accepted. UR / Client number:(if relevant) Name Address DOB: Fill in or attach the patient label
