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Sample Patient Agreement Forms - nida.nih.gov

Patient Agreement FormsIntroductionThis resource 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. These documents contain statements to help ensure patients understand their role and responsibilities regarding their treatment ( , how to obtain refills, conditions of medication use), the conditions under which their treatment may be terminated, and the responsibilities of the health care provider.

I will keep all appointments set up by my doctor (e.g., primary care, physical therapy, mental health, substance abuse treatment, pain management) I will bring the pill bottles with any remaining pills of this medicine to each clinic visit. I agree to give a blood or urine sample, if asked, to test for drug use. Refills

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