Controlled Substance Agreement

As a Client of Phoneconsultation, I do hereby agree to be bound by the following polices regarding the use of controlled substances:

1. I understand that prescriptions for controlled substances will not be provided without me first scheduling a consultation. I agree not to telephone the provider and ask for refills. I understand that under no circumstances do I expect the provider or the office staff to make a exception to this policy.

2. I understand that I must call the office at least one week in advance to schedule an pharmacy consultation. This will eliminate the situation of needing an “emergency” appointment simply to obtain new prescriptions of regular medications

3. I understand that for the treatment of my chronic pain condition I am expected to take my medication on a strictly controlled schedule – not whenever I think I need something.

4. I understand that my prescriptions for my controlled substances (and all other prescriptions, for that matter) are to be held in strict confidence. My medications are my personal business and no one other that my provider, my pharmacist and I need have any knowledge of what I require to help treat my pain or any other medical conditions unless I choose to let somebody else have this knowledge. I understand that any breach of this confidence is my sole responsibility and that I may suffer the consequences. I will not hold my provider responsible for my personal breach of the confidentiality of my provider-patient relationship.

5. I agree to only use one pharmacy unless I fully inform my provider (before the fact) that I am changing to a new pharmacy. I understand that “shopping around” to different pharmacies, like doctor shopping and other forms of drug seeking behaviour, makes it appear that I may be stock piling, misusing, misappropriating, abusing, selling or otherwise mishandling my medication.

6. I pledge to be responsible at all times for the medication that is in my possession. My medication will not be lost, stolen, inadvertently dropped down the toilet or garbage disposal, run through the dishwasher, washer dryer, eaten by the dog, ever “loaned” or sold to anyone or otherwise carelessly diverted to anyone. I understand that the medication is best kept hidden in a locked box, and that I will never leave controlled substance on a car seat, in the glove compartment, my lunch box, the kitchen or dining room table, a window sill or nightstand or even in a unlocked medicine cabinet. I believe that all such actions are inviting trouble and are inexcusable.

7. I will never be in the possession of prescriptions for bottles of controlled substances from more than 1 provider at the same time. I will not be guilty of doctor-shopping or drug-seeking behaviour.

8. I will never use illicit drugs (including but not limited to marijuana, cocaine, methamphetamines, PCP) or any other controlled substances not specificity prescribed to me by my provider. I agree to be subject to urine drug screens whenever requested by my drug provider. If the expense of such testing is not covered by my insurance I agree to be reasonable for payment in fall.

9. I will never sell, loan, borrow, steal, or other wise misuse my controlled substances, or that of any other person.

10. I understand that any violation of the above policy provisions may result in my immediate dismissal from Phoneconsultation.com services.