Patient Form

Provides a template for an agreement that describes the patient's responsibilities and commitment not to engage in certain activities.

Gives patients information about the medication they will be taking for pain management and ensures that the patient and physician comply with all State and Federal regulations concerning the prescribing of controlled substances.

Includes two sample patient agreement forms that can be used with patients who are beginning long-term treatment with opioid analgesics or other controlled substances. Helps ensure patients understand their role and responsibilities regarding their treatment and those of the healthcare providers, as well as the conditions under which their treatment may be terminated.

Provides a sample treatment contract for office-based opioid addiction treatment with buprenorphine.

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.

Provides a sample treatment agreement for buprenorphine/Naloxone.

Provides information on the potential benefits and risks of opioid medications and documents that both the patient and provider agree on a care plan.

Asks the patient to agree to follow the treatment plan, keep appointments, and take medicine as prescribed.

Details the material risks associated with the medication and risk of physical dependence.

Provides a sample treatment agreement for buprenorphine/naloxone.