Appendix L

SAMPLE PATIENT CONTRACT FOR OPIOID TREATMENT

PLEASE PRINT CLEARLY

Patient name:

Physician name:

The patient must initial the space provided to indicate that he/she understands each provision of the contract:

_____ I understand that this Agreement is an important element in the trust in a doctor/patient relationship and that my doctor will treat me only subject to the terms of this Agreement.
_____ I understand that if I break this Agreement, my doctor will taper off my use of this medicine in a manner that will not cause withdrawal symptoms and then cease immediately to prescribe these medications.
_____ I understand that another consequence of breaking this Agreement is that my doctor may recommend I enter drug-dependence treatment program.
_____ I am willing to submit to psychiatric treatment, psychotherapy, and/or psychological treatment if my doctor concludes that it is necessary.
_____ I will communicate fully with my doctor about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain.
_____ I will not use any illegal controlled substances, including marijuana, cocaine, heroin, etc.
_____ I will not use legal controlled substances not prescribed by my doctor.
_____ I will use alcohol sparingly, and never when I am driving or operating machinery.
_____ I will not share any prescribed medication with anyone.
_____ I will safeguard my pain medication from loss or theft and understand that lost or stolen medications will not be replaced.
_____ I agree that my prescriptions for pain medications will not be refilled over the phone, and will only be made at my office visit, or during regular office hours Monday through Friday. No refills will be available during evenings or on weekends.
_____ I agree to have all my prescriptions for pain medication filled at only one pharmacy, and that it will be the pharmacy of my choice.

Name of pharmacy: _____________________________________
Address: ___________________________
Telephone #:____________________________
FAX #:_____________________________________________

_____ I give permission to the doctor and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including the state Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medication. I give my doctor permission to provide a copy of this Agreement to my pharmacy, primary care physician and local emergency room. I further agree to waive any applicable privilege or right of privacy or confidentiality with respect to these permissions.
_____ I will submit to a blood or urine test if requested by my doctor to determine my compliance with this agreement.
_____ I will use my medicine only at the prescribed rate.
_____ I understand that use of my medicine at a greater rate will result in my being without medication for a period of time.
_____ I will bring unused pain medicine to every office visit.
_____ All of my questions and concerns regarding treatment have been adequately answered.
_____ A copy of this document has been given to me.

This Agreement is entered into on this _____ day of ___________,

Patient signature: __________________________________________________________________________

Physician signature: ________________________________________________________________________

Witnessed by: (please print name) _________________________________________________________________

Witness signature: __________________________________________________________________________

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