MEDICATION CONSENT AND AGREEMENT

Note: Please write your initials next to each of the statements below after having read it.

_____ I agree not to call requesting medication refills over the phone. I understand that no medications will be called‑in, no prescriptions will be faxed, and no medications will be changed over the phone. I also understand that no new medications will be started over the phone. The only way that I will be able to get my prescriptions will be by keeping my appointments.

_____ I agree to request refills of all medications only during my regular appointment. I understand that it is my responsibility to know how much medicine I have left, and whether or not I will have enough medication to last until my next appointment. Prescriptions will be provided only during my appointments. Should I forget to get my refills during my appointment would mean that I may not have enough medication to last until my next visa. I understand that should I get home and realize that I did not get my prescriptions; my pain physician will not be calling them in. I understand that I will need to get another appointment just to get those prescriptions.

_____ I agree not to request prescriptions or refills after normal business hours, nights, holidays, or weekends. I understand that it is the responsibility of each patient to plan ahead enough such that medications do not run out at night or during weekends.

_____ I agree to take medications only as prescribed and directed. I understand that taking less than prescribed is acceptable, especially if I do not need as much to get the desired effect, or if I have problems and side effects with the prescribed dose. Nevertheless, I understand that the opposite is not true. I also understand that I should never take more than prescribed, especially without the physician's expressed consent. This consent can only be obtained from my physician during a regularly scheduled appointment. I understand that calling the clinics to obtain this consent over the phone is unacceptable and not recommended. I understand that there will be no early refills.

_____ I agree to always bring my medications to the appointments. I understand that pills may be counted in order to assess my use of the medications. I also consent to having some of my medication be sent out for analysis and proper identification, on the sole discretion of my treating physician.

_____ I agree not to request and/or accept narcotics from any other sources. I understand that this is called "Doctor Shopping" and it is illegal in the state of North Carolina. I agree to provide a list of all of my medicines to any physician offering such prescriptions, and never to attempt hiding or omitting to inform about any controlled substances that I may be taking.

_____ I agree never to share, give, lend, or sell any of my medication to anyone. I also agree never to barrow or buy these medications from illegal sources. I understand that it is unwise, dangerous, and illegal. I understand that in the event that I was to break this agreement and resulted in a fatality, I will be personally and solely responsible, liable and held accountable for the other person's death.

_____ I agree to always bring a complete updated list of my medications to each appointment.

_____ I agree to submit myself to random drug testing as part of my medication management.

_____ I agree to always check with my pharmacist whenever I am given a new medication, to see if there may be any drug interactions with the other medications that I am taking. I understand that over‑the‑counter medications and herbs may also interact with prescription drugs.

_____ I understand that the pain clinic will not prescribe, rewrite, or renew any medications that I may have received or may be taking for non‑pain related reasons (blood pressure medicines, diabetes medication, asthma medication, nicotine patches, antibiotics, etc.). I understand that the pain clinic will write for pain medications only.

_____ I understand that the pain clinic will not be writing for "nerve medicines". If I have problems with my "nerves' (anxiety, depression, nervousness, panic attacks, suicidal ideations, etc.) I understand that I need to see a psychologist or a psychiatrist for help. The pain clinic will not prescribe things like Valium (diazepam), Ativan (lorazepam), Xanax (alprazolam), or any other medicine for my "nerves".

_____ I understand that lost or stolen medications will not be replaced. I understand that the pain clinic does not accept police reports as evidence of medications having been stolen. Lost prescriptions will not be ‑replaced.

_____ I hereby certify that I have read this form or have had it read to me, that I understand all of it, and that I have had a chance to have all of my questions answered to my satisfaction. By voluntarily signing this form, I give my consent for the treatment of my pain with opioid pain medicines, and other medications commonly used in the treatment of pain. I also understand that signing this document does not mean than my pain physician is obligated in any way to prescribe or continue prescribing any of these medications to me. I also understand that failure to comply with the above regulations may result in the immediate discontinuation of the controlled substances been prescribed, and possible discharge from the program.

Patient signature ____________________________________________Ý Date __________________________

Witness to above ____________________________________________Ý MRN __________________________