Doctor/Patient Prescription Agreement

The agreement between   (Patient Name) and MedStop One is for the purpose of establishing a formal outline of the 'Agreement' between the Doctor and Patient and further clarifying the condition for the prescription and the use of controlled medications prescribed by the doctor to the patient. Doctor and Patient agree that this agreement is an essential factor in establishment and maintenance of the trust and confidence necessary in a doctor/patient relationship.

Doctor for the Patient:

• I understand that I must bring my prescription bottles and any unused medication to each office visit.
• I understand that a reduction in the intensity of my prescription and improvement in the quality of life are the goals of this program.
• I realize that all of the medications have potential side effects and I will have the recommended lab studies required to keep the regimen as safe as possible.
• I realize that it is my responsibility to keep others and myself from harm, including the safety of my driving.  If there is any question of impairment of my ability to safely perform any activity, I agree that I will not attempt to perform the activity until my ability has been evaluated or I have not used my medication for at least four days.
• I will not use any illegal substance including marijuana, cocaine, etc.
• I will not share, sell or trade my medication for money, goods or services.
• I will not get pain medication from any other healthcare provider.  I understand that it is against the law to do so.
• I will safeguard my medication from loss or theft, and agree that the consequences of my failure to do so are that I will be without my medication for a period of time.
• I agree to waive any applicable privilege or right of privacy or confidentiality with respect to the prescribing of the controlled medications prescribed, and I authorize the Doctor and the pharmacy to cooperate fully with any city, state or federal law enforcement agency, including the investigation of any possible misuse, sale or any other diversion of my meds.  I authorize the Doctor to provide a copy of this Agreement to my pharmacy.
• I agree that I will submit to a blood and/or urine test if requested by my Doctor to determine my compliance with my regimen of controlled medication(s).
• I agree that I will use my medication at a rate no greater than the prescribed rate and that use of my medication at a greater rate will result in my being without medication for a period of time.
• Doctor and Patient agree that this Agreement is essential to the Doctors ability to treat the Patients condition(s) effectively, and that the failure of the Patient to abide by the terms of this Agreement may result in the withdrawal of all prescription medications by the Doctor and the Termination of the Doctor/Patient relationship.

This Agreement is entered on this Date of:   (mm/dd/yyyy).