The purpose of this agreement is to give you information about the medications you will be taking for psychiatric management and to assure that you and your physician comply with regulations concerning the prescribing of controlled substances. The physician’s goal is for you to have the best quality of life possible given the reality of your clinical condition. The success of treatment depends on mutual trust and honesty in the physician/patient relationship and full agreement and understanding of the risks and benefits of using controlled substances to treat psychiatric illness.

1. You should use one physician to prescribe and monitor all controlled substances.
2. You should use one pharmacy to obtain all controlled substances prescribed by your physician. Should the need arise to change pharmacies; will be notified.
3. You should inform your physician of all medications you are taking including herbal remedies, since controlled substances can interact with over-the-counter medications and other prescribed medications, especially cough syrup that contains alcohol, codeine or hydrocodone.
4. You will be seen on a regular basis and given prescriptions for enough medication to last from appointment to appointment. You are to take medications as prescribed.
5. Prescriptions will be refilled during appointments.
6. You are responsible for keeping your medication in a safe and secure place, such as a locked cabinet or safe. Stolen medications should be reported to the police and to your physician immediately. Lost or stolen prescriptions will not be refilled or replaced.
7. It is against the law to give or sell your medications to any other person.
8. The use of alcohol or other illicit drugs and controlled substances is dangerous and could result in death or serious medical complication and therefore they should never be mixed together.
9. There are side effects with controlled substances that may include, but are not limited to: sedation, dizziness, respiratory depression, fatigue, a-motivation, confusion, disinhibition, sleep walking, decreased libido, memory problems, incontinence, respiratory failure, addiction, dependency and abuse, seizures, severe withdrawal if stopped quickly, low blood pressure, fainting, fetal abnormalities if taken in pregnancy, anorexia, insomnia, headache, mood swings, irritability, nervousness, weight changes, diarrhea, agitation, palpitations, increased blood pressure, libido changes, aggression, visual changes, sweating, high abuse, dependency, addiction potential, psychosis, mania, heart attack or arrhythmia, sudden death, stroke, rashes including StevensJohnson Syndrome (necrotic rash)
10. If you have a history of alcohol or drug misuse/addiction, you must notify the physician of such history since the treatment with controlled substances for psychiatric conditions may increase the possibility of relapse. A history of addiction does not, in all instances, disqualify one for treatment of psychiatric illness with controlled substances, but starting or continuing a program for recovery is a must.
11. If the responsible legal authorities have questions concerning my treatment, as might occur, for example if I obtained medications at several pharmacies, all confidentiality is waived, and these authorities may be given full access to Remedy Therapy records of controlled substances administration. In the event that you are arrested or incarcerated related to legal or illegal drugs, refills on controlled substances will not be given to you.
12. You agree and understand that your physician reserves the right to perform random or unannounced urine drug testing. If requested to provide a urine sample, you agree to cooperate. If you decide not to provide a urine sample, you understand that your doctor may change your treatment plan, including safe discontinuation of your controlled substances when applicable or complete termination of the doctor/patient relationship. The presence of a non-prescribed drug(s) or illicit drug(s) in the urine can be grounds for termination of the doctor/patient relationship. Urine drug testing is not forensic testing. You accept responsibility for the cost of the urine drug test in the event that your healthcare coverage will not cover the cost of this test.
13. You should not use any illicit substances, such as cocaine, marijuana, etc. while taking these medications. This may result in a change to your treatment plan, including safe discontinuation of your prescribed controlled substances when applicable or complete termination of the doctor/patient relationship.
14. Any evidence of drug hoarding, acquisition of any controlled substances from other physicians (which includes emergency rooms), uncontrolled dose escalation or reduction, loss of prescriptions, or failure to follow the agreement may result in termination of the doctor/patient relationship.

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