A Consent Form for Treatment
The purpose of this consent for treatment is to protect your access and our ability to prescribe you controlled (scheduled) medications in the care of your medical condition.
The long-term use of such substances as narcotic pain medications (opiate analgesics), benzodiazepine tranquilizers, and sedatives is controversial because of uncertainty regarding the extent to which they provide long-term benefit. There is the risk of an addictive disorder developing or of relapse occurring in a person with a prior addiction. The extent of this risk is not certain but is generally considered to be no more than the incidence in the general population.
As these medications have potential for abuse or diversion, strict accountability is necessary especially when utilization is prolonged. For this reason the following policies must be agreed to by you, the patient, as consideration for, and a condition of, the willingness of the physician to consider the initial and/ or continued prescription writing of controlled substances to treat your medical illness.
_____1. I agree to treatment with: Hoyman Hong, M.D.
_____2. All controlled substances must come from the physician identified in the consent form, or during his/her absence, by the covering physician, unless otherwise specified for exception.
_____3. I agree to whenever possible obtain my prescribed medications from this office at the same pharmacy.
_____4. I agree to update this office of any new medical diagnoses or medications as well as any adverse side effects I experience.
_____5. My prescribing physician has your permission to discuss all diagnostic and treatment details with dispensing pharmacists and/or other medical professionals who are involved in your health care.
_____6. I understand and agree not to share, sell, or otherwise permit others to have access to my medications.
_____7. I agree to safeguard my prescription medications from individuals including family members as well as any children. I recognize that these medications may be hazardous or lethal to a persons who is not tolerant to their effects such as children.
_____8. I accept and understand that if I abruptly discontinue or stop my prescription pain medications an abstinence syndrome (withdrawal) will likely develop.
_____9. I agree to unannounced urine or serum toxicology screens (drug testing). I further understand that the presence of unauthorized substances or other illegal drugs may be grounds for discharge the medical practice.
_____10. I will be prepared to bring in the original prescription bottles to each office visit.
_____11. I understand that my medications may not be replaced if they are accidently lost, damaged or destroyed. An exception may be made if your medication has been stolen. A police report regarding the theft must be provided for the file.
_____12. I agree and understand that my prescriptions may be issued early if I or the physician is unavailable when a refill is due. An appointment will be made for the next mutually available time.
_____13. I agree and understand that my prescriptions for pain medications will typically be contingent on maintaining regularly scheduled appointments and that early refills will generally not be given.
_____14. I authorize the provider to cooperate fully with any local municipal, city, state or federal law enforcement agency in the investigation of any possible misuse, sale, or other diversion of my pain medication. I further agree to waive any applicable privilege or right of privacy or confidentiality with respect to our cooperation in a formal investigation.
_____15. I understand that in chronic conditions prescription pain medication management is one form of treatment and its continued use is contingent on evidence of benefit.
_____16. I understand that failure to adhere to these policies may result in cessation of therapy with the controlled substance prescribed by this office and physician.
_____17. I affirm that I have full right and power to sign and be bound by this agreement, and have read, understood, and accept all of its terms.
Patient Name (printed)