Prescriptions

Policies Regarding Prescriptions for Pain

PATIENT NAME:
SSN:
DATE OF BIRTH:

You will be given enough pain medication, taken as prescribed, to last until your next scheduled appointment. Please be advised that if you take more than the prescribed amount you risk serious injury to yourself, including death, and no additional medication will be prescribed until your next scheduled appointment.

If you find that a specific pain medication does not work for you, we will only exchange it pill for pill with a new prescription. The remainder of your old prescription must be brought in to us or turned in at your pharmacy.

This office DOES NOT call in any pain medication over the telephone, except for post- operative pain medication. Please schedule an appointment if you need refills on your medication. Be careful to allow at least one-weeks time to schedule the appointment.

We will NOT refill narcotic prescriptions, which have been lost or misplaced. Please be responsible in keeping up with your narcotic prescriptions.

Thank you for your consideration.

This is to certify that I have read and understand the policy stated above.

____________________________________________________________
Patient's SignatureDate

______________________________ Rev 5/2/01
Witness