Dr. Nguyen’s formal contract for the patient and provider to sign and be scanned into the chart:

(Please add a comment in the Social History Narrative stating "Narcotic Medication Agreement signed and scanned on date: ***)

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NARCOTIC MEDICATION AGREEMENT

Message from Penn Family Care: The purpose of this agreement is to protect your access to controlled substances and to protect our ability to prescribe for you. Because these drugs have potential for abuse, strict accountability is necessary when use is prolonged. For this reason, you, the patient, understand the following policies:

- All controlled substances must come from the physician whose signature appears below or, during his/her absence, by the covering physician within Penn Family Care only.

- It is understood that failure to follow these policies may result in stoppage of therapy with controlled substances by this physician.

- Forty-eight (48) hours notice is required when needing to reschedule appointments. Failure to give this notice may result in termination of opioid therapy.

- You will have your narcotic prescriptions filled at one pharmacy only. If your pharmacy cannot or will not fill your prescriptions, for ANY reason, you will have them filled at the Presbyterian Hospital Pharmacy.

- You will receive at most ONE prescription per month. Make sure you receive the full amount from your pharmacy. Do not accept a partial prescription.

- If your insurance will not allow you the monthly amount, you will be responsible to pay for the rest.

- Prescriptions are given at scheduled appointments. Please do not phone for prescriptions after hours or on weekends.

- Do not lose your prescriptions for controlled substances. Lost prescriptions will not be replaced by Penn Family Care.

- If you feel sleepy, do not drive.

- Any changes to your medications will be determined at your next appointment. Do not call for changes between appointments.

- Do not abruptly stop your medication as you may experience withdrawal symptoms.

- You must not take other medication that may interact with your narcotics without first consulting with your physician (i.e., anxiety, tranquilizers, sleeping pills, sedatives, antihistamines).

- You must not drink alcohol while taking these medications because combining these drugs with alcohol may cause severe drowsiness, low blood pressure and even death.

- You will not sell, share or permit others to have access to your medications. You will not take someone else’s medications.

- Do not chew, break, cut or crush your pills unless instructed to do so by your doctor.

- You agree to give blood or urine samples for testing and/or psychological counseling at the request of the Penn Family Care. You agree to bring all pill bottles and pills when requested by your doctor.

Patient Signature:

_______________________

.name

.td

Clinician:

_______________________

.me

.td