OPIOID AGREEMENTOpioid Agreement • December 28th, 2012
to be included on plan section of office visit note if patient is on >60 MME)Opioid Agreement • January 25th, 2022
Per the HFHS Pain Protocol, patient has agreed to reduce @his@ opioid use prior to surgery to below 60 MME or by 50% of current MME (whichever is greater). It has been explained to the patient that reduction in opioids prior to surgery promotes better outcomes - including better pain control after surgery, early ambulation after surgery, and timely discharge from the hospital. Patient understands that we will inform @his@ prescribing provider of the above and has been instructed to follow-up with them for further assistance.
Opioid AgreementOpioid Agreement • March 30th, 2021
SIDE EFFECTS Tolerance:• I may need higher doses and more often Constipation My pain may worsen over time Nausea or vomiting Physical dependence:• If this medicine is stopped suddenly, I may experience diarrhoea, stomach cramps, goose bumps and runny nose Drowsiness, confusion, lethargy or clouded thinking• driving may be affected Psychological Dependence:• I may experience a strong desire to take more of this medicine• I may experience an uncontrollable need to seek out and use this drug, despite harmful consequences Hormone and sexual function changes:• Cause impotence or lose my sex drive• Changes in my menstrual periods• Osteoporosis Loss of balance Depression and anxiety Slowed breathing Itchy skin Problems with my teeth and dry mouth Problems with sleeping and worsened sleep apnoea Hallucinations Weight gain and change in appetite If pregnant – my baby may become dependent and may experience withdrawal when born An overdose if too much is taken or used with other medicines, alco
Johnston Pain Management, P.A. Opioid Agreement FormOpioid Agreement • October 26th, 2021
I, understand that following these guidelines for opioid therapy is important to my safety and necessary to continuing opioid therapy with Johnston Pain Management. I agree to follow ALL the requirements of this agreement. I understand that per the recommendations of the Federal Drug Enforcement agency and the North Carolina Medical Board, this form will be reviewed at 6-month intervals. I am completely responsible for every item on this list:
ContractOpioid Agreement • November 12th, 2009
PAIN & WELLNESS CLINIC Zhengyu (Zane) Hu, M.D.Diplomat American Board of Physical Medicine & RehabilitationBoard Certification in Pain Medicine
Agreement between Charleston Pain and Rehabilitation and .Opioid Agreement • September 18th, 2020
Opioids (also called narcotics) are medicines used to treat pain and are controlled by special federal and state laws to prevent drug abuse and diversion. This agreement between Dr. Jeffrey Buncher and you, the patient , is drawn up to prevent any misunderstandings about prescribing Opioids for the treatment of you pain. This agreement is to protect your access to these medications and to protect our ability to prescribe them for you. This will insure both you and Dr.
OPIOID AGREEMENTOpioid Agreement • April 11th, 2007
Opioid AgreementOpioid Agreement • May 10th, 2016
The purpose of this agreement is to protect your access to necessary pain medications and to protect our ability to prescribe for you.
OPIOID AGREEMENTOpioid Agreement • October 5th, 2015
• I understand that the medication will probably not completely eliminate my pain, but is prescribed in order that I may become more functional and improve my quality of life. I agree to try NON-NARCOTIC MEDICATIONS and participate in modalities such as PHYISCAL THERAPY and INJECTIONS in order to reduce or eliminate the need for narcotics.
Opioid Agreement for Center for Pain Management S.C.Opioid Agreement • April 10th, 2013
DNA Advanced Pain Treatment Center Opioid AgreementOpioid Agreement • December 2nd, 2014
