Patient Name:
Date of Birth This agreement is between my provider, Jennifer Jerome, MSN, APRN, FNP-BC and me, (patient name) habit-forming medication(s) because previously received treatment(s) have not provided sufficient relief of symptoms. I understand that it is unlikely that any medication will eliminate all of my symptoms. I also understand that controlled medication(s) will be prescribed for me as long as the extent of my condition indicates the need and that I comply with all the terms and conditions of this agreement or until I am seen by a specialist. By signing this agreement, I fully understand the indications, risks, benefits, and other options of treatment that my provider has explained. I accept the risk to take these medication(s) and will comply with the statements of this contract. Risks and Potential Complications * Chemical and physical dependence, addiction * Drowsiness, confusion, central nervous system depression * Respiratory depression * Nausea, itching * Severe constipation, difficulty with urination * Reduced or absent sexual drive/function If I take more medications than my provider, Jennifer Jerome, MSN, APRN, FNP-BC prescribed such as non- prescribed drugs, drug amounts, combinations of other drugs, alcohol and illicit substances; serious and life- threatening complications may occur. These complications include, but are not limited to: * Coma * Organ damage or failure * Death I also understand that if I take my medication(s) sooner or more often, I am risking the above complications and if I suddenly stop taking my medication(s), I could develop life threatening withdrawal symptoms. Female patients only: I understand that there are both known and unknown risks/hazards to an unborn infant if the mother takes narcotic medication. The risks/hazards include, but are not limited to, addiction of the infant with withdrawal at birth. I take full responsibility for notifying my provider if I am suspected/confirmed to be pregnant. I further understand that controlled substance(s) may be discontinued during my pregnancy. Terms of Agreement: 1. Only one pharmacy will be used for filling my controlled substance prescriptions. The selected pharmacy is:
Pharmacy Phone: 2. I agree to receive controlled substance medication(s) ONLY from REVIVE Center for Health & Wellness, PLLC.
3. In order to obtain refill(s) for controlled substance medication(s), I understand that an appointment must be scheduled with the provider. I further understand that it is my responsibility to assure that I have enough medication to last through the weekend, holiday, and/or after hours (4:00 PM-9:00 AM). 4. I understand that REVIVE Center for Health & Wellness, PLLC does not accept telephone requests for narcotic prescriptions, and I must be seen at my regularly scheduled appointment with the provider in order to receive a prescription. 5. If another provider is covering Jennifer Jerome, MSN, APRN, FNP-BC in her absence after hours, on holidays or weekends, he/she may NOT refill medications. 6. I hereby authorize the release of information that allows the provider(s) and/or staff to communicate and collaborate with other health care and insurance professionals to discuss my treatment and my progress. This includes those who are currently or previously involved in my care. 7. I will notify REVIVE Center for Health & Wellness, PLLC about medication side effects. I understand that if a serious side effect or reaction occurs after hours, on weekend, or holidays, I should immediately seek emergency assistance from the nearest hospital. 8. Prescription dosages have been thoroughly explained to me by my provider. I understand that I shall not change the dosage amount or alter the time schedule of the prescribed medication without direction to do so by my physician. 9. I understand that controlled medication(s) must always be kept in a safe place and the patient is responsible to store his/her medication(s) in safe/secure place, away from reach of children and others. It has been thoroughly explained to me that the policy doesn't allow replacing medication(s)/prescription(s) that are misplaced, lost, or stolen. I understand if my medication(s)/prescription(s) are stolen, I must deliver a police report to my provider, and she will verify its authenticity by calling the police before considering replacement. A second such event may lead to termination of our contract. 10. I must keep appointment(s) recommended by provider. 11. I understand the benefits of controlled medication(s) will be evaluated regularly by using criteria of my general functioning, increase in activities of daily living, pain level, mood, and presence/absence of significant side effects. 12. I agree to participate in psychotherapy if it is deemed to be necessary for me. 13. I agree to submit urine or blood samples to drug screening when ordered. 14. I have been given information about the use of controlled medication, including the risks and side effects listed above. I chose to take them because the benefit outweighs the risk. 15. I will not hoard controlled medication(s). 16. I will not alter controlled prescription(s). 17. I will not sell or swap controlled medication(s). 18. I will not drink alcohol within 24-48 hours of taking controlled medication(s). 19. I understand that my provider may notify me of a noted violation of this contract, resulting in discharge from the practice. 20. I agree to allow REVIVE Center for Health & Wellness, PLLC to contact other pharmacies to discuss the medications I have obtained. 21. I understand that controlled medication(s) may impair my abilities to drive or operate machinery. I will not drive or operate machinery after taking pain medications until after the next dose of medication is due. 22. I understand that I might have controlled medication(s) discontinued at any time and for any reason, upon the decision of my provider. With notification of such discontinuance, a 30 day supply of the medication will be provided. I attest to the following (Please check the box for each line): I am not using illegal drugs or prescription drugs prescribed to someone other than myself. I am not using multiple controlled substance prescription sources. I am not under treatment for substance (drug or alcohol) dependence or abuse. I have never been involved in the sale, illegal possession, or transport of drugs. Females patients only: I attest to the following (Please initial each line): I am not pregnant, and I will inform the staff of REVIVE Center for Health & Wellness, PLLC if I become pregnant or intend to become pregnant. I understand there may be harmful effects on an unborn infant if I take narcotic medication(s) during my pregnancy. I was provided with sufficient details about narcotics to make an informed decision about therapy pros and cons. I understand the possible side effects and complications of controlled substance treatment. Release from Liability: I release REVIVE Center for Health & Wellness, PLLC from liability from any medical or social conditions or consequences related to controlled medication therapy and/or discontinuation of narcotic medication(s). Acknowledgements/Agreement: I hereby acknowledge that the content of this contract has been explained to me. In addition, I have either read the contract or had it read to me. I was offered many opportunities to ask questions and discuss any unclear aspects of this contract. I acknowledge that I fully understand that my failure to comply with any term set forth within this contract will result in termination of this contract and my care and medication at REVIVE Center for Health & Wellness, PLLC. Patient Signature:
Date:
