Medication Agreement

Medication Agreement Form

Treatment with medications is only one part of an entire toolbox used to address medical and mental conditions. Other forms of treatment will be individually discussed with your doctors because everyone is an individual.

This agreement in no way is intended to accuse you the patient of any wrongdoing. Medications even “controlled” can be a great tool for overcoming pain, addressing dependence, and increasing the changes of escaping some addictions.

Prescriptions medications once picked up at your pharmacy are your responsibility

Some medications referred to as “controlled” include but are not limited to:

-Buprenorphine / buprenorphine-naloxone (suboxone)

-Alprazolam (xanax)

-Hydrocodone with acetaminophine - (lortab, norco, vicodin)

-Clonazepam (Klonopin)

-Zolpidem (Ambien)

-Amphetamine/dextroamphetamine (Adderall)

All medications should be taken as prescribed. Do NOT increase the amount of the medication you take; Do NOT increase how often you take your medication unless directed by your doctor / NP FIRST.

Prescriptions are written so that you will have enough medication to last until your next appointment. This is one of the many reasons why keeping your appointments is so important to your care. Our appointments are done by tele-med so that travel time to and from the appointment is eliminated.

If labs are ordered there is a reason, please have them done at a certified labs like CPL, Quest ect Some medications require blood levels to titrate other medications require regular monitoring of things like liver functions.

We understand on rare occasions life emergencies happen. If you must reschedule your appointment, please do so as soon as you can. We ask for 24-hour notice so that the appointment can be offered to someone else if necessary. Because of the preparation that goes into appointments the evening prior we are going to begin charging a no-show fee/last minute cancellation charge.

If you must have a refill of a controlled medications (the list above) to prevent you from running out due to a rescheduled appointment it is called “a bridge”.Bridge prescriptions come with a set of rules covered elsewhere.

We are in the office during regular office hours. Medication refills are not available in the evenings, wee hours of the morning, weekends or during holidays.

Your prescriptions are for YOU and only you. You agree not share, sell or ‘loan” your medication to someone else. If someoneyou know needs medications for pain or treatment,they need to see a doctor, (we are honored when patient’s refer othersto our practice)

Medication Agreement Form

Your medications are YOURS

Please avoid taking other people’smedications. If your medications are not controlling your symptoms, please let your MAPS provider know.

You are responsible for the safe storage of your medications. You MUST keep your medications secure as they could be fatal to small children and pets.

***If a child or pet accidentally eats or ingest your medications, please seek professional assistance, or call 911.

*** Poison Control Human (800) 222-1222***

*Poison Control Animal (800)213-6680- $65.00 fee listed*

Should your medications be lost or stolen the replacement prescriptions are the decision of the doctor and made on a case-by-case basis. If your medications are considered controlled medications - (reference to that list again) get lost or stolen You will need to call the police, file a report, and fax a copy that report to your MAPS provider prior to requesting another prescription. Again,replacement refills are a decision made by your doctor on a case-by-case basis.

Our doctor reserves the right to refuse early refills of controlled medications. In certain circumstances you may be advised to go to the ER if suddenly stopping a medication poses risk to your health.

When beginning treated at MAPS it is important that you let your health care provider know what medications you are taking. This includes both prescribed medications and any “street drugs” you are using. We can’t help if we don’t have the complete story.

After treatment begins. It is your responsibility not to take controlled medications (back to that list above) from another doctor without letting the docs at MAPS know. If you get pain medications from our doctor and then get the same pain medications from another doctor that looks like drug diversion and can be caused to change treatment strategies or in rare instances terminate treatment. The exception is emergencies like bad car accidents, broken bones ect . If that happens let your MAPS doctor know as soon as possible and the incident should definitely be mentioned at your next appointment.

Because some medications do not mix with other medications using the same pharmacy for all your medications is important to your health and safety. Pharmacists go to school a long time to learn the different chemicals in medications and they help make sure your medications don’t interact in a way that could be harmful.

If you are having annoying side effects or have simple questions, please let our doctors know. This can be done though our patient portal (encouraged) or you can call the office and leave a message (non- emergencies only). Please understand our response will not be immediate but we will respond within 24 during regular office hours.

For complex discussions or complicated issues that cannot wait, an extra appointment maybe necessary.

Medication Agreement Form

Which brings us to this last part If you are having life threatening symptoms like not being able to breath, swallow or you begin acting funny or start hallucinating by all means it is an EMERGENCEY! DO NOT WAIT!

***ALL ENERGENCIES SHOULD GO TO THE EMERGENCEY ROOM OR CALL 911 ***

I have read and understand the above information and if I have any questions, I will let my provider know at our next visit.

Patient Name *

Date *

Patient Signature Name *

Patients Signature: *

Use your mouse or finger to sign in the box below.

MEDICATION AGREEMENT

MAPS for Recovery

Medication Agreement Form

Medication Agreement Form

Medication Agreement Form

MEDICATION AGREEMENT

MEDICATION AGREEMENT

MAPS for Recovery

Medication Agreement Form

Medication Agreement Form

Medication Agreement Form

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