1. I understand that my provider and I will work together to find the most appropriate treatment for my chronic pain. I understand the goals of treatment are not to completely eliminate pain but to control my pain in order to improve my ability to function. Chronic Opioid therapy is only ONE part of my overall pain management plan.
2. I understand that my provider and I will continually evaluate the effect of opioids on achieving the treatment goals and make changes as needed. I agree to take the medication at the DOSE and FREQUENCY prescribed by my provider. I agree not to increase the dose of opioids on my own and understand that doing so may lead to the discontinuation of opioid therapy.
3. I will attend all appointments, treatments and consultations as requested by my providers. I will attend all pain appointments and follow pain management recommendations. I understand that failure to keep appointments may lead to discontinuation of treatment.
4. I will tell my providers about the level and description of my pain, the effect of the pain on my daily life and how well the medicine is helping to relieve my pain.
5. I recognize that my chronic pain represents a complex problem, which may benefit from physical therapy, psychotherapy, behavioral medicine, and other pain control strategies. I agree to cooperate and actively participate in all aspects of the pain management program to maximize functioning and improve coping with my condition. If treatment for my condition is available, I agree I will not refuse the treatment just so the opioids will be continued. I understand that I have the right to refuse any procedure, but that does not mean that my provider must continue to prescribe narcotic or opioids medications.
6. The risks and benefits of taking opioid medications have been explained to me. I understand them. Opioids can cloud judgments and affect reflexes and motor skills. The patient will not participate in activities that would endanger themselves or others while using these medications.
7. I agree I will not use any illegal controlled substances, including marijuana, cocaine, Heroin, etc. I agree I will not use any prescription medications obtained illegally, or obtain them from friends or relatives.
8. I agree I will not abuse alcohol. If my provider advises, I will not use any alcohol.
9. I agree I will not share, sell or trade my medication with anyone.
10. I agree to protect my pain medicine from loss or theft. Lost or stolen medicines will not be replaced. I will report stolen medication to the police and to my provider and will produce a police report of this event.
11. I agree I will not attempt to obtain any opioid medicines from another doctor or provider without informing the Southwest Ohio Pain Center doctor first. I agree to have my opioid prescriptions filled only at pharmacy listed on page four (4) of this agreement.
12. I agree that refills of my prescriptions for pain will be made only at the time of an office visit or during regular office hours. No routine refills will be available during evenings, after 4 pm, on weekend, holidays, or through the emergency room. Medications will not be mailed or refilled without being seen at monthly pain clinic appointment (if patient is receiving his opioids from the pain clinic).
13. I am responsible for keeping track of the amount of medications left and to plan ahead for arranging the refill of my prescriptions in a timely manner so I will not run out of medications.
14. I agree to bring in all unused pain medicine when requested.
15. I will submit urine for drug testing if requested by my provider to determine my compliance with their program of pain control.
16. I authorize the Southwest Ohio Pain Center to cooperate fully with any official, including the state’s Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medicine.
19. If it appears to the physician that there are no demonstrable benefits to my daily function or quality of life from the controlled substance, I will agree to gradually taper my medication as directed by the prescribing physician.
17. I will accept generic brands of my prescription medications.
18. I understand that I may become tolerant to, addicted to or have complications from the opioid medications. If this occurs, the medication may be changed or tapered and other methods of pain control may be used. If necessary, I will permit referral to addiction specialists.
20. I understand that if I violate any of the above conditions, my provider may choose to stop writing opioids prescribed for me. Discontinuation of the medications will be coordinated by the provider and may require specialist referrals.
21. I understand that if I or a family member are verbally or physically abusive to any staff member or engage in any illegal activity such as altering a prescription, that the incident may be reported to other physicians, local medical facilities pharmacies and other authorities such a the local police department, drug enforcement Agency, etc. as deemed appropriate for the institution.
21. I understand that if I or a family member are verbally or physically abusive to any staff member or engage in any illegal activity such as altering a prescription, that the incident may be reported to other physicians, local medical facilities pharmacies and other authorities such a the local police department, drug enforcement Agency, etc. as deemed appropriate for the institution.
22. Understanding that suddenly stopping some pain medicines can cause problems such as: withdrawal symptoms
heart attack
stroke
seizures
permanent damage
disability or death
23: I understand Southwest Ohio Pain Center will share medical information with my referring physician and primary care physician.
Acknowledgement of Deception to Obtain a Dangerous Drug Statute 2925.22 ORC
No person, by deception, as defined in 2913.01 of the Revised Code, shall procure the administration of, a prescription for, or the dispensing of, a dangerous drug or shall possess an uncompleted preprinted prescription blank used for writing a prescription for a dangerous drug. “Deception” as defined in 2913.01 of the Ohio Revised Code, means knowingly deceiving another or causing another to be preventing another from acquiring information, or by any other conduct, act or omission that creates, confirms, or perpetrates a false impression in another, including false impression as to law, value, state of mind, or other objective or subjective fact.
I hereby acknowledge the contents of the Deception to Obtain a Dangerous Drug Statute. Additionally, I understand that if I fail to provide, omit, or withhold information from a physician, dentist, hospital, or any other medical attention in which I have received a prescription for a controlled substance/ dangerous drug, could result in the filing of criminal charges against me.
Furthermore, this advisement is NOT meant to prevent me from obtaining any medical attention, but merely that by law I have an obligation to provide full and accurate information regarding recent medical attention and any medications received.
Pain Management Agreement and State Statute 2925.22 ORC
All of my questions and concerns regarding treatment have been adequately answered. A copy of this document has been given to me.
Medication Refill information:
1. Advance notice of 5-7 business days is required for all non-opioids refills of the prescriptions
2. Requests for scheduled refills for non-opioids must be telephoned to the pharmacy only during regular office hours Monday-Friday (8:30 am – 4:00 pm). Refills will not be made at night, on holidays, or on weekends.
3. Most controlled substance can not be telephoned in to the pharmacy.
4. I will be given a (30) thirty days supply each month.
5. All hard copies of the opioids prescriptions must be hand delivered to the pharmacy by myself
This agreement will supersede all other agreements
• I have received a copy of Southwest Ohio Pain Center’s No Show Policy
• By signing below I indicate that I understand AND agree to ALL the terms of the above agreement. I have received a Copy of this for my own records.
Pain Management Agreement and State Statute 2925.22 ORC
All of my questions and concerns regarding treatment have been adequately answered. A copy of this document has been given to me.
Medication Refill information:
1. Advance notice of 5-7 business days is required for all non-opioids refills of the prescriptions
2. Requests for scheduled refills for non-opioids must be telephoned to the pharmacy only during regular office hours Monday-Friday (8:30 am – 4:00 pm). Refills will not be made at night, on holidays, or on weekends.
3. Most controlled substance can not be telephoned in to the pharmacy.
4. I will be given a (30) thirty days supply each month.
5. All hard copies of the opioids prescriptions must be hand delivered to the pharmacy by myself
This agreement will supersede all other agreements
• • I have received a copy of Southwest Ohio Pain Center No Show Policy
