This form is developed in partnership and has co-ownership with the South AustralianMedication Agreement • November 8th, 2023
This information is confidential and will be available only to relevant staff and emergency medical personnel. Medication Agreements that are modified, overwritten or illegible will NOT be accepted.
Annual Authorization from a Parent/ Legal Guardian and Healthcare Provider is Required for All MedicationMedication Agreement • July 2nd, 2024
This form is developed in partnership and has co-ownership with the South AustralianMedication Agreement • February 18th, 2020
The legal guardian or adult student can complete the medication agreement authorising education and care staff to administer medication as instructed. All sections of the ‘Authorisation’ section must be checked to confirm authorisation to administer in an education or care service by the legal guardian or adult student. A treating health professional may assist the legal guardian or adult student to complete this form.
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.
This form is developed in partnership and has co-ownership with the South AustralianMedication Agreement • June 2nd, 2022
The legal guardian or adult student can complete the medication agreement authorising education and care staff to administer medication as instructed. All sections of the ‘Authorisation’ section must be checked to confirm authorisation to administer in an education or care service by the legal guardian or adult student. A treating health professional may assist the legal guardian or adult student to complete this form.
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
Annual Authorization from a Parent/ Legal Guardian and Healthcare ProviderMedication Agreement • August 7th, 2017
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.
Medication Agreement for Allergy TreatmentMedication Agreement • January 15th, 2007
Medication Dose Route Frequency Medication used for Side Effects Medication Dose Route Frequency Medication used for Side Effects Printed Name of Prescribing Practitioner: □ This order is effective for the period from to Month / Day / Year Month / Day / Year □ The student has been instructed by me or a member of my staff when & how to use his/her EpiPen. □ This student is capable of self administration of anaphylaxis treatment. □ This student is not able to carry his/her allergy medication. Prescribing Practitioner Signature Date
Desert Shores Pediatrics Stimulant/Non-Stimulant Medication AgreementMedication Agreement • August 27th, 2021
Desert Shores Pediatrics (DSP) is committed to providing the safest care for our patients with Attention Deficit Hyperactivity Disorder (ADHD). Drug Enforcement Agency (DEA) controlled substances may be used as a therapeutic option to manage symptoms associated with this condition. The following agreement is designed to help improve treatment outcomes, reduce the risk of adverse events and ensure proper use of all ADHD medications while adhering to both state and federal laws. The word “I”, “me”, or “my” refer to the patient; in cases where the patient is under 18 years of age, the parent or legal guardian is authorizing this agreement on behalf of the child.
Hamm Clinic Medication AgreementMedication Agreement • February 27th, 2024
This agreement is to be reviewed, understood, and signed as part of the intake process for patients considering medication management at Hamm Clinic.
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 Facts and Agreement: Mercaptopurine, 6-MP, 6-Mercaptopurine (Purinethol), Azathioprine (Imuran)Medication Agreement • August 29th, 2006
6MP and Azathioprine are antimetabolite immunosuppressive drugs that work by inhibiting DNA synthesis in lymphocytes. Lymphocytes are one type of white blood cell that plays a role in the body’s immune response. These medications are used in treating patients with inflammatory bowel disease (IBD), leukemia, autoimmune hepatitis, polycythemia vera, and psoriatic arthritis. For patients with IBD these medications can decrease the need for steroids, help patients who have been steroid dependent, and/or help patients who have multiple relapses after steroid withdrawal. These medicines can help with healing of fistulas, improve overall clinical improvement, and maintain remission. With taking these medications, close follow up in the office is needed for blood work, monitoring dosage, symptoms and side effects.
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.
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
Annual Authorization from a Parent/ Legal Guardian and Healthcare ProviderMedication Agreement • August 7th, 2017
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.
Annual Authorization from a Parent/ Legal Guardian and Healthcare Provider is REQUIRED for ALL MedicationMedication Agreement • August 6th, 2020
MEDICATION AGREEMENTMedication Agreement • August 21st, 2007
We are committed to doing all we can to treat your chronic pain condition. In some cases, controlled substances are prescribed as a therapeutic option in the management of chronic pain, and this form of treatment 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 Dr. Siegel’s medical practice and the words "you”, "me," or "my" refer to you, the patient.
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.
ContractMedication Agreement • October 28th, 2019
The purpose of this agreement is to prevent misunderstandings about crtain medications you will be taking for pain management. This is to help both you and Apollo Pain Management to comply with the law regarding controlled pharmaceuticals (pain and nerve medicines).
ContractMedication Agreement • April 8th, 2019
This document has been developed by, and has co-ownership with the Department for Education and the Women’s and Children’s Health Network Disability Services; Access Assistant Program
Southeast Kansas Orthopedic Clinic Medication AgreementMedication Agreement • August 31st, 2024
Welcome to the Southeast Kansas Orthopedic Clinic, we appreciate that you chose us to provide care for your orthopedic needs. There are times as a patient being seen at this facility you will be given prescriptions for anti-inflammatory or pain medication. Legislation has placed many new restrictions on these medications, and we are taking all measures to reduce your reliance on this type of treatment.
VOLUNTEER BEHAVIORAL HEALTH CARE SYSTEM POLICY & PROCEDURESMedication Agreement • January 22nd, 2019
Subject: Medication Agreement References: VBHCS, Regulatory & Contractual Entities Approved By: Medical Director Forms & Attachments: Reference to Best Practice Standards for Benzodiazepines & Guidelines for use of Benzodiazepines in Office Practice, Medication Agreement for Sedative/Hypnotics (Form #270A), Medication Agreement for Stimulants (Form #270B), Cognitive Behavioral Therapy (CBT) ExclusionForm #270C Effective/Revised Date: 01-01-99; 9/2002, 1/2006, 10/2007, 6/2015, 12/2018 Policy #: QM-MR-270
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
Medication Agreement - 1Medication Agreement • October 21st, 2020
AGREEMENT & POLICY: to be completed for ALL studentsMedication Agreement • April 7th, 2023
⮚ The Deerfield Academy medication policy has been developed to help ensure the health and safety of all of our students. Parents must inform the Deerfield Academy Health and Wellness Center of ALL medications and/or supplements a student takes or has in their possession during the school year by completing and, as warranted, updating the attached Student Medication List. This includes prescription, over-the-counter (OTC), and other types of medications, such as herbs, homeopathic and otherwise.
This form is developed in partnership and has co-ownership with the South AustralianMedication Agreement • August 20th, 2020
This information is confidential and will be available only to relevant staff and emergency medical personnel. Medication Agreements that are modified, overwritten or illegible will NOT be accepted.
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
This form is developed in partnership and has co-ownership with the South AustralianMedication Agreement • February 8th, 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
Medication AgreementMedication Agreement • November 26th, 2013
This is a medication contract between and Universal Pain Specialists. The purpose of this contract is to outline policies regarding controlled substances, including narcotics (Hydrocodone, Oxycodone, Morphine, Fentanyl, etc). This agreement will help makes sure we comply with state and federal regulations. A trial of opioid therapy will be considered for moderate to severe pain with objective of reducing pain and improving function. The success of this treatment will be based on honesty and trust between the physician and the patient. Please read through this contract thoroughly and ask for clarifications or questions about anything you do not understand.
MEDICATION AGREEMENTMedication Agreement • March 16th, 2020
