Medication Agreement

 Medication Agreement & Refill Policy

As part of your treatment, our medical staff may prescribe medications for you. As you know, 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 the prescribed guidelines. No prescriptions will be written for you unless you accept the following agreement.
You will agree to follow the dosing schedule prescribed to me by my doctor.
You will agree to never share, sell or exchange my medications with anyone for any reason.
You will agree that you are solely responsible for the safekeeping of my medications. You will treat my medications as you would any valuable   possession. You know that Your physician will not replace LOST OR STOLEN prescriptions or controlled medications.
You will agree that you will not drive or operate heavy machinery while taking medications that may cause drowsiness or impair cognitive function.
You will agree to notify your physician's staff if you experience any adverse effects or dosage problems with your prescribed medications. You may be asked to bring any unused medication to your physician for disposal.
You will agree that if you receive a controlled substance prescription from your physician, you are not allowed to accept controlled substance prescriptions from any other physician without your doctor’s consent.
You will agree to use only one pharmacy for your pain-related medications. In the event, that circumstances require the use of another pharmacy, You will notify your physician, or their staff, of this immediately and provide them with all pertinent contact information.
You understand that medication refill prescriptions involving narcotic pain medicine require a scheduled appointment with your primary physician in the office. Narcotic pain medication refills will not be called into a pharmacy. Narcotic dosages will not be increased by phone.
You will agree to keep all scheduled appointments. You understand that no medications will be given for canceled or no-show appointments. You understand that if you are more than 15 minutes late to my scheduled appointment time, you will have to reschedule for another time.
You understand that you can not be seen at the office without a scheduled appointment for ANY reason.
The physician's staff phone triage hours are 8:00am to 3:00pm, Monday through Friday for Non-Emergency medication questions and refill requests. You know that you can not call this line more than two times in any day.
You know that you can be asked to bring any or all of my prescribed medications to your office appointment or at a random time for a prescription compliance check (Pill Count).
You understand that your physician will write and dispense narcotic medication prescriptions on a 30 day basis. In order to receive another narcotic medication prescription you must schedule another office visit within 30 days of the date on your current prescription so your physician can properly evaluate your progress.
You understand that abusive behavior or harassment toward any staff can not be tolerated. The physicians will determine what actions can be considered harassment on a case-by-case basis and, if warranted, You can be dismissed from the practice.
You understand that dealing with a forged, falsified or altered prescription will result in my immediate dismissal by your provider.

You understand that your physician reserves the right to PERFORM A URINE DRUG SCREEN AT ANY TIME WHILE I AM BEING TREATED WITH PRESCRIBED CONTROLLED SUBSTANCES. If the results of the urine drug screen do not reflect medicine prescribed by your doctor, or test positive for illegal drugs, You understand that you can be dismissed immediately from the practice.


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