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Agreement For Long Term Controlled Substance Prescriptions

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AGREEMENT FOR LONG TERM CONTROLLED SUBSTANCE PRESCRIPTIONS

This agreement outlines the terms and conditions for receiving long term controlled substance prescriptions.

Page 1

Patient Information

Email*

Full Name*

Date of Birth*

Address*

Phone Number*

Emergency Contact Name*

Emergency Contact Phone Number*

Description:This agreement is for long-term controlled substance prescriptions. It outlines the responsibilities of both the patient and the prescribing physician. By signing this agreement, the patient agrees to follow the prescribed treatment plan, only obtain medications from the prescribing physician, and submit to drug testing as required. The prescribing physician agrees to monitor the patient's treatment, adjust the medication as necessary, and provide ongoing care. This agreement helps ensure safe and responsible use of controlled substances for chronic pain management.

This agreement is designed for patients who require long-term controlled substance prescriptions for chronic pain management. It outlines the responsibilities of both the patient and the prescribing physician to ensure safe and responsible use of these medications. By signing this agreement, the patient agrees to follow the prescribed treatment plan, only obtain medications from the prescribing physician, and submit to drug testing as required. The prescribing physician agrees to monitor the patient's treatment, adjust the medication as necessary, and provide ongoing care. This agreement helps establish clear expectations and guidelines for the use of controlled substances in the treatment of chronic pain.

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Lansing Annual Exam/ Vaccination Intake Form

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Date of Arrival*

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