Sample
Pain Management Contract
|
| Between____________________________________________________________,
patient |
| And
_______________________________________________________________, physician. |
| The following agreement establishes
boundaries for the use of controlled substances in the treatment of chronic pain of benign
origin. I will receive a prescription of controlled medication while participating in a
pain management program at _________________________________________________,
clinic/office. |
I will be able to receive treatment only if I
abide by the following rules:
- I will use the medication only as directed by the physician
- I will not receive replacement for lost or stolen medication
or prescriptions.
- I will not expect to receive additional medications before
the next scheduled visit, even if the prescription runs out.
- I will receive controlled medication or mood altering drugs
only from the physician named above or, in his absence from his explicit designee.
- I will accept generic medication if it performs like the
name brand.
- I will present my prescription only at a pharmacy mutually
agreed upon.
- I agree to submit to urine or blood tests to detect the use
of other medications, substances or other health effects whenever my physician finds it
necessary.
- If it appears to the physician that my daily functioning and
quality of life are not improved by the use of controlled medication, I will gradually
taper off that medication as prescribed by the physician. I will not hold any member of
the treating team responsible for ill effects caused by discontinuation of the controlled
medication, provided that I receive 30 days notice of termination.
- I recognize that my chronic pain is a complex problem that
may respond to other measures used in combination with the medication. Such treatments may
include physical therapy, psychotherapy, behavioral approaches and counseling. It may
require family involvement. I agree to participate actively in all aspects of the pain
management program, as directed by my physician, who can be reached at
________________________________________.
- I recognize that the combined measures will take time and
effort. They are designed only to relieve my pain and improve my functioning.
- If I violate these rules, my treatment can not be continued.
|
_________________________________
Patient Signature |
Date:______________________________ |
_________________________________
Physician Signature |
Date:______________________________ |
_________________________________
Signature of family member or
Significant other |
Date:______________________________ |
|
|
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