Medical Providers
Sample 1 Treatment Agreement
Provides a sample treatment agreement for buprenorphine/naloxone.
Notice of the Use of Controlled Substances for the Treatment of Intractable Pain and Patient's Informed Consent
Details the material risks associated with the medication and risk of physical dependence.
Agreement To Use Pain Medicine for the Long Term
Asks the patient to agree to follow the treatment plan, keep appointments, and take medicine as prescribed.
Informed Consent and Agreement for Opioid Therapy of Pain
Provides information on the potential benefits and risks of opioid medications and documents that both the patient and provider agree on a care plan.
Sample 2 Treatment Agreement
Provides a sample treatment agreement for buprenorphine/Naloxone.
Sample Informed Consent Form
Helps ensure patients who are beginning long-term therapy with opioid analgesics understand the side effects, risks, conditions, and purpose of their treatment. Facilitates clear communication between patients and healthcare providers about long-term opioid therapy, defines treatment expectations, and resolves any patient questions or concerns.
Sample Treatment Agreement
Sample Patient Agreement Forms
Agreement for Opioid Maintenance Therapy for Non-Cancer/Cancer Pain
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