Combined Prescriber-Patient Agreement & Informed Consent
This consent and agreement for treatment between the undersigned patient and prescribers at Innovative Medicine is to
establish clear conditions and consent for the prescription and safe use of pain control ing opioid medications or other
control ed substances prescribed by the healthcare provider for the patient.
These medications are being prescribed for the purpose of treating pain and opiate dependence in some cases. Along with
medications, other medical care may be prescribed to improve the ability to do daily activities. This may include exercise, use of
non-opioid analgesics, physical therapy, psychological evaluation/ counseling, weight management, classes on managing pain,
integrative therapies such as acupuncture and Healing Touch, or other beneficial therapies or treatment.
The Patient agrees to and accepts the fol owing conditions for the management of pain medication prescribed by the
Physician/Nurse Practitioner/Physician’s assistant for the patient. Failure to comply with the conditions in this agreement may
result in these medications being discontinued and possible termination of the prescriber/patient relationship.
I understand that a reduction in the intensity of my pain AND improvement in my daily life functions are the goals of this
program. Should it become evident that these goals are not being met with the use of pain medications, I understand the
medications may be weaned and/or discontinued.
1. I must comply with the fol owing guidelines:
a. I wil only use this medication for purposes of pain control and opiate dependence in some cases.
b. I wil take the prescribed medication only at the dose and frequency prescribed.
c. I wil not increase or change the dose or frequency without consulting my prescriber first.
d. If I use my medication at a faster rate than prescribed I wil be without medication for a period of time and this could result in
dependence withdrawal that is uncomfortable and may include an uneasy feeling, increased pain, irritability, bel y pain,
serious physical or psychological effects.
f. I will not attempt to get pain medication from any other healthcare provider.
g. I wil inform al other healthcare providers (ER, surgeon, dentist, etc.) that I am receiving pain
medications from this prescriber. Should I receive any other prescriptions for pain medication I wil inform this provider of the
exact medication I received by the next business day.
h. I am expected to keep scheduled office appointments.
i. I wil obtain all medications from one pharmacy.
j. I am required to keep my prescriber up to date on all medications that I am taking especially other sedating medications such
as medications for anxiety (Xanax, Valium, Klonopin, Lorazepam, etc.), for depression or other mental health conditions, for
drowsiness such as Benadryl), for sleep: prescription (Ambien, Restoril, Lunesta, etc.) and over-the counter (Tylenol PM, etc.)
for cough (Tussinex, etc.) and for muscle relaxation (Flexeril, Soma, Zanaflex, etc).
k. I wil consent to random drug screening at the provider’s request. Unexpected results may result in changing or discontinuing
my medications. l. I agree to bring my pain medication into the office to be counted if requested.rst Do N
m. I wil not use this medication with any alcohol containing beverages.
n. I wil not use any il egal substances including marijuana, cocaine, amphetamines, etc.
o. I will not attempt to forge or call in a prescription for myself or any other individual. I will not attempt to alter the
prescription in any way written by the prescriber. I understand that these are prosecutable offenses and may be reported to
p. If I am arrested or incarcerated related to legal or il egal drugs my medications may be discontinued.
q. I wil not share, trade or sel my medication for money, goods or services. I understand that these are prosecutable offenses
r. I am responsible for the protection and security of my medications. I wil keep them in my possession or in a secure place at
al times not al owing anyone else, including family, friends, children and at-risk adults, access to these medications.
s. If my medications are lost or stolen a re-evaluation of my competence to continue on these medications may be performed.
2. I understand refil s of my prescriptions should be addressed in person at scheduled office visits. I wil not stop by the office
without an appointment and I understand I wil not be seen and refil s wil not be addressed without an appointment. Refil s
may not be made nights, weekends or holidays.
3. I agree to be evaluated by a psychiatric specialist, psychologist and/or addiction specialist at any time during my treatment at
my doctor’s request. I agree to the release of those records and reports to my prescriber. If, in their opinion I am not a
candidate for further opioid treatment, I understand my medications may be weaned and discontinued.
4. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to the prescribing of my pain
medications. I authorize the Prescriber and pharmacy to cooperate fully with any city, state, or federal law enforcement agency
in the investigation of any possible misuse, sale or other diversion of pain medication. I authorize the Prescriber to provide a
copy of this agreement to my pharmacy and my other
5. I understand that it is my responsibility to keep others and myself from harm, including the safety of my driving. If there is
any question of impairment in my ability to safely perform any activity, I agree not to attempt to perform such activity until I
6. I further accept full responsibility for any sickness, injury or untoward event which may happen to anyone else as a result of
my taking any of the medications prescribed by this provider.
7. I understand that the long-term effects of opioid therapy have yet to scientifical y be determined and treatment may change
throughout my time as a patient. I understand, accept and agree that there may be unknown risks associated with the long-
term use of opioids and my doctor wil advise me as knowledge and training advance and wil make appropriate treatment changes.a7
8. I understand that al medications have potential side effects. For pain medications these include but are not limited to:
addiction, physical dependence, pseudoNonaddiction, chemical dependence, constipation which may be severe enough to
require medical treatment, difficulty with urination, drowsiness, cognitive impairment, nausea, itching, depressed respiration,
reduced sexual function and adverse effects or injury to the organs. A distinct clinical syndrome, “hyperalgesia syndrome”, has
been described in the literature and can actual y result in increased pain from continual and escalated does of opioid
9. I understand if I take more medication than prescribed or combine opioids with other sedating medication or alcohol it could
result in coma, organ damage, or even death. These interactions are especial y dangerous if I have lung disease such as COPD or
10. Women of child bearing age: I understand if I am planning to become pregnant, if I become pregnant or if I am suspicious
that I am pregnant, I wil notify my prescriber immediately. I further accept that any medication may cause harm to my
embryo/fetus/baby and hold the prescriber and al staff harmless for injuries to the embryo/fetus/baby.
I have read the above and have had all my questions answered. I know that pain can be managed with many types of
treatments. If I am receiving pain medications for a trial period, for an expected acute or subacute condition or for a specific
timeframe such as a work related injury then this agreement applies to the timeframe that this provider prescribes pain
Opioid medication is only one part of my pain management plan of care. There is limited scientific data to suggest that using
opioids over 4-5 months wil lower my pain and or improve my daily function. There is some scientific information that suggests
using opioids can increase my pain, make me feel less wel , and increase my risk of unintentional death directly related to the
opioid medication. I know that if my provider feels my risk from opioids is greater than my benefit, I may have my opioids
compassionately lowered or removed altogether.
I understand that no agreement can anticipate all events in medical treatment that may arise and that for myself and my heirs, I
wil hold harmless the prescriber, the practice, the clinic, its officers, owners and staff for al resultant problems. By my
signature below, I agree to al the above terms both explicit and implicit.
Patient _______________________________________________________ Date___________________
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