Agreement for Pain Management I understand that I have a right to comprehensive pain management. Due to the nature of these prescriptions, I would like to enter into a treatment agreement to help prevent chemical dependency. I understand that failure to follow any of these agreed upon statements may result in my primary care physician not providing ongoing opiate therapy for me. I, ______________________________________________, agree to undergo opiate medication treatment at this clinic. I agree to the following statements.

1. All my medication concerns will be brought chiefly to my primary care physician ______________________________.

2. I will use only one pharmacy. It is _________________________________. 3. I will not accept any opiate or other controlled substance prescriptions from any

other physician, unless approved by my primary care provider. 4. I will phone my primary care physician within a week to report an emergency

room visit. I will avoid going to emergency rooms for pain management of my chronic condition. This agreement does not prevent me from going to an emergency room for new acute pain of any nature.

5. I am responsible to make sure that I do not run out of my medications on weekends or holidays, because abrupt discontinuation will cause severe withdrawal symptoms.

6. I may obtain refills during regular hours. My primary care physician or one of his or her partners may take up to 48 hours to refill my medication. I may be asked to come in for a visit when a refill is requested. Excessive phone calls to office or harassment of office staff may result in a discontinuation of opiate therapy.

7. I understand that I must keep my medications in a safe place and that my primary care physician will not supply additional refills of any medications that I may lose. If my prescriptions are stolen, my primary care physician will refill my medications if a copy of the police report is provided.

8. I will not give, sell, or trade my prescriptions to anyone else. 9. I certify that the information given to my physician is correct. 10. I consent to urine drug screens as requested by my physician.

Termination Clauses

A. My physician may terminate this agreement at any time if he or she has cause to believe that I am not complying with the terms of this agreement, or that I have made a misrepresentation or false statement concerning my pain or my compliance with the terms of the is agreement.

B. I understand that I may terminate this agreement at any time. If the agreement is terminated, I will no longer be able to obtain opiate medication from this clinic. I will seek care with another physician for opiate medication therapy, and will strongly consider treatment for chemical dependency if clinically indicated. ______________________________________________ __________________ Patient Signature Date

Patient label