Controlled Substance Agreement Template
(letterhead/logo of company/facility if available)
Treatment agreement for [Controlled Substance.Name]
This agreement is in place to ensure that patients and caregivers have clear communication and safe, effective procedures when patients use[Controlled Substance.Name].
For most patients with (type of condition being treated),[Controlled Substance.Name] is effective at (treatment result). However, it is possible [Controlled Substance.Name] will not work well for you or your (symptoms).
Most people can take these drugs safely, but some people do experience side effects. (See below)
Most patients do not have serious side effects or drug interactions. Unfortunately, some do experience side effects and must stop the medication(s). Common side effects include (describe side effects typical to this controlled substance). Uncommon but potential side effects include (describe uncommon side effects of this controlled substance).
Alternative treatment options
(These are sample options and should be replaced with specific options relevant to the patient and treatment plan)
Rehabilitative physical therapy
What you need to do
(Some of these are sample actions and should be replaced with specific actions relevant to the patient and treatment plan)
Use your medications ONLY as directed by your medical provider.
Realize that (controlled substance) is only one part of treatment.
Maintain activity every day and try to consistently increase activity level.
Work with your provider and follow treatment recommendations in addition to taking prescribed medications.
7) I will NOT combine any prescribed Controlled Substances with alcohol consumption. Any urinary drug screening positive for both alcohol and Controlled Substances will be considered a violation of this agreement. _____ (initial)
8) I will NOT combine any prescribed Controlled Substances with illegal/street/recreational drugs. Any urinary drug screening that is positive for both illicit substances and prescribed Controlled Substances will be considered a violation of this agreement. _____ (initial)
9) I will be responsible for scheduling and keeping appointments for Controlled Substance refills at least every (number) month(s). I understand that NO refills will be written outside of my appointment, and I will NOT contact the office for refills of these medications outside of an appointment. _____ (initial)
10) I will be responsible for having a functional phone number that the office will use to contact me about random urinary drug screening and/or pill counts. I understand that once contacted by the office, either directly or by voicemail, I will have 24 hours to report, or my inability to do so will result in a violation of this agreement. _____ (initial)
11) I understand that not all insurance providers cover the cost of drug screening and that I may be responsible for part of or the entire amount owed. _____ (initial)
12) I understand that I will not receive any Controlled Substances until my provider has reviewed my medical records. If I am a new patient, I understand that it is my responsibility to ensure my medical records have been obtained from my previous provider. _____ (initial)
13) I will not lie or tell misleading information to my provider or any of the (name of medical facility) staff. _____ (initial)
14) I will not get angry with or make threatening remarks to my provider or their staff in an attempt to get Controlled Substances, and I realize that doing so could result in a violation of this agreement. _____ (initial)