Controlled substances, such as narcotics, tranquilizers and barbiturates are very useful, but have high potential for misuse. They are intended to relieve pain specifically to improve function and/or ability to work, not simply to feel good. Because my physician is prescribing these medications, I agree to the following conditions:
- I am responsible for my controlled substance medications. If the prescription is lost, misplaced or stolen, or if I use it up sooner than prescribed, I understand that it will not be replaced.
- I will not request or accept controlled substance medication from any other physician or individual while I am receiving medication from Pain Management Associates Medical Group.
- There will be no early refills. Prescription for refills will be written at my next office visit. They will not be made if I run out early for any reason including if I lose a prescription or spill/misplace the medication.
- I agree to comply with random urine, blood or breath testing to document the proper use of medications.
- I understand that if I am told that I am impaired by another person, I will not drive a motor vehicle or operate any other heavy machinery.
- I further understand that driving a motor vehicle may not be allowed at times while taking controlled substances. It is my responsibility to comply with the laws of the state while taking these medications.
- I agree to waive any applicable privilege or right of privacy or confidentiality with respect of prescribing my pain medication.
- I understand that side effects of sedation, itching, nausea, vomiting, difficulty urinating, constipation and other side effects are possible. I further understand that a possibility of addiction and the probability of physical dependence exist and I consent to all of these risks.
- I understand that suddenly stopping this medication may result in an abstinence syndrome. I also understand that in addition to the side effects listed above, a possibility of respiratory depression and even death exists from these medications. If I feel very sleepy, I will not overtake these medications, even of my pain level or other problems are very great.
- I understand that violating any of the conditions of this agreement may result in dismissal from this practice. Violation of this agreement may also result in narcotics no longer being prescribed.
- I further agree that my narcotics prescription may be stopped or decreased at any time for any reason by my physician or any other Pain Management Associate physician.