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Pain Agreement



I UNDERSTAND THE PURPOSE OF THIS AGREEMENT ISTO PREVENT MISUNDERSTANDINGS ABOUT CERTAIN MEDICATIONS THAT I WILL BE TAKING FOR PAIN MANAGEMENT. THIS IS TO HELP ME AND MY DOCTOR COMPLY WITH THE LAW REGARDING CONTROLLED MEDICATIONS.

I UNDERSTAND THAT IF I BREAK THIS AGREEMENT, SPECIALTY PAIN MANAGEMENT WILL STOP PRESCRIBING MY PAIN MEDICATIONS.

I AGREE THAT I WILL NOT MIX ALCOHOL WITH PAIN MEDICATION.

I AGREE THAT DRIVING OR OPERATING ANY TYPE OF MACHINERY WILL NOT BE ALLOWED WHILE J AM BEING PRESCRIBED OPIOID MEDICATION AS THIS COULD BE CONSIDERED "DRIVING UNDER THE INFLUENCE" BY LAW.

I AGREE THAT I WILL NOT USE ANY ILLEGAL SUBSTANCES, INCLUDING MARIJUANA

I WILL NOT INCREASE OR DECREASE THE DOSAGE OF MY MEDICATION WITHOUT THE CONSENT OF THE PRESCRIBING PHYSICIAN. IP

I FEEL THAT ADJUSTMENTS IN THE MEDICATION DOSAGE IS REQUIRED, I AGREE TO CONTACT THE PRESCRIBING DOCTOR AT SPECIALTY PAIN MANAGEMENT FOR AN APPOINTMENT.

I WILL NOT SHARE MY MEDICATIONS WITH ANYONE, NOR WILL I TAKE ANOTHER PERSON 'S MEDICATION.

I WILL NOT SELL MY PRESCRIBED MEDICATIONS, EITHER TO PATIENTS OF SPECIALTY PAIN MANAGEMENT OR TO OTHERS.
I WILL NOT RECEIVE ANY PATN MEDICATIONS FROM ANY OTHER DOCTORS. IF I AM GIVEN A PRESCRIPTION FOR A CONTROLLED SUBSTANCE, I AGREE NOT TO PILL THE PRESCRIPTION UNTIL J HAVE CONTACTED THE OFFICE AND HAVE DISCUSSED IT WITH A PROVIDER AT SPECIALTY PAIN MANAGEMENT .

I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO SAFEGUARD MY MEDICATION. SHOULD MY MEDICATION BE LOST, STOLEN, OR DESTROYED, UNDER NO CIRCUMSTANCES WILL IT BE REPLACED.

I WILL NOT CONTACT THE OFFICE TO SCHEDULE FOR AN EARLIER APPOINTMENT IF I HAVE OVER-TAKEN MY MEDICATION.

I UNDERSTAND THAT THERE MAY BE RJSKS ASSOCIATED WITH THE USE OF PAIN MEDICATION, INCLUDING RISK OF DEATH, RESPIRATORY DEPRESSION , BOWEL AND BLADDER DYSFUNCTION, SEXUAL DYSFUNCTION, CHANGE OF APPETITE WITH POSSIBLE WEIGHT GAIN OR LOSS, CHANGE OF COORDINATION (WHICH MAY INTERFERE WITH DRIVING, OPERATING MACHINERY AND FINE MOTOR Movement) AND OTHERS.

I UNDERSTAND THAT THE CONTINUOUS USE OF PAIN MEDICATION MAY RESULT IN DEPENDENCE, ADDICTION, CHANGE IN PERSONALITY, AND SLEEP CHANGES.

I WILL REPORT ANY CHANGES IN MY MENTAL STATE, AS WELL AS POSSIBLE SIDE EFFECTS FROM MY MEDICATION.

I AGREE TO SUBMJT TO RANDOM URINE DRUG TESTING ANO/OR PILL COUNT AT THE REQUEST OR NEED OF THE PROVIDERS ON AN AS NEEDED BASIS TO MONITOR MEDICATION COMPLIANCE WITH RECOMMENDED TREATMENT.

I UNDERSTAND THAT SUDDEN STOPPING OF PAIN MEDICATION CAN LEAD TOREBOUND PAIN, WITHDRAWAL SYMPTOMS, SEIZURES AND OTHER SYMPTOMS. I HAVE BEEN INFORMED NOT TO STOP ANY PAIN MEDICATION SUDDENLY UNLESS DECIDED JOINTLY BY MYSELF ANO MY PAIN DOCTOR.

I AGREE TO ALLOW MY PAin PHYSICIAN TO REVIEW ANY OF MY PAST MEDICAL OR PSYCHOLOGICAL RECORDS.

I AGREE THAT WHEN I HAVE ANY CONTACT WITH DR.NARWAN I OR ANY STAFF MEMBER, I WILL NOT BE RUDE, AGGRESSIVE, SWEAR AND/OR BE DISRUPTIVE WITH ANY MEMBER OF THE OFFICE.    

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. J AGREE AND UNDERSTAND THAT NON-COMPLIANCE WITH THE ABOVE WILL RESULT IN FORMAL DISCHARGE WITH NOTIFICATION TO MY PRIMARY CARE PHYSICIAN AND OTHER TREATING PHYSICIANS.