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narcotic.html

A template for a narcotic contract for the patient who has been placed on narcotics for chronic pain.

HTML icon narcotic.html — HTML, 3 kB (3828 bytes)

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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
"http://www.w3.org/TR/html4/loose.dtd">

<html>
<head>
<title>Missed Appointment Template</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">

<style type="text/css">
body {font-size: 1em; font-family:"Times New Roman", Times, serif; background-color: #FFFFFF;}
</style>

<style type="text/css" media="print">
* {color: #000000;}
</style>

</head>
<body contenteditable onLoad="document.designMode = 'on';">

<div style="text-align: center;"><font size="+2">##clinic_name##</font></div>
<p>##first_last_name##</p>
<p>##today##</p> 
I understand that I am receiving narcotics from Dr. ##provider_name_first_init## to treat my pain. I agree to the following conditions under which the medication is prescribed:
<ul><li>I will take my narcotic medication(s) at the dose and frequency prescribed.</li>
<li>I will not seek narcotic medication(s) from another physician. Only Dr. ##provider_name_first_init## will prescribe narcotic medications for me.</li>
<li>I will use only one pharmacy, ##Which Pharmacy Do they use?=The Pharmacy##,to fill my narcotic medication(s) with full consent of my physician and pharmacist to exchange information verbally or in writing.</li>
<li>I will not take narcotic medication(s) in larger amounts or with increased frequency than is prescribed by Dr. ##provider_name_first_init##.</li>
<li>I will not give or sell my narcotic medication(s) to anyone else including family members, nor will I accept narcotic medication(s) from anyone else.</li>
<li>I will not use over-the-counter narcotic medication(s) such as Tylenol #1, Tylenol #2 or 222s.</li>
<li>I understand that if I run out of my narcotic medication(s) for any reason, or lose the medication, Dr. ##provider_name_first_init## will NOT prescribe extra medication. I will have to wait until the next prescription is due.</li>
<li>I agree to participate in any medical, psychological or psychiatric assessments recommended by my doctor.</li>
<li>I understand that if I breach any of these conditions, Dr. ##provider_name_first_init## may choose to stop writing my narcotic medication(s) prescriptions for me.</li>
<li>I also agree to random urine drug testing. If I am found to be using illicit (illegal) drugs or narcotic medications not prescribed for me as above, this alone may/will result in the loss of privilege to receive these medications at the clinic.</li></ul>
By signing this contract, I allow my doctor to share information regarding my use of narcotic medication(s) with other community physicians, pharmacies, emergency departments, or any health professional.
<br><br>Patient:<span style="text-decoration: underline;">
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&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>Signed ##today## 
<br><br>Witness:<span style="text-decoration: underline;">
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&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>Signed ##today##
</body>
</html>

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