1. Patients receiving narcotic medications from pain management may not receive any narcotics prescripts from any other physician or clinic office. If you are receiving any narcotic medications from another physician’s office, clinic or emergency room, you may be discharged from our practice.
2. I will take the medications as prescribed and not more unless approved by my physician, and I will NOT take another person’s prescribed narcotic medication.
3. All time- released medications should be taken whole. They are not to be crushed, ground up or mutilated before taken.
4. Your medications are your own. Keep them in a safe place. Do NOT share them with your spouse, friends, or anyone else.
5. Prescriptions will be accompanied by an office visit.
6. It is the policy of the practice that only the patient will be able to sign for prescriptions.
7. All patients must understand that narcotic medications are potentially dangerous.
8. All patients receiving narcotic prescriptions will sign and receive a copy of the agreement.
9. I understand that alcohol may potentate the effects and duration of my medication. I acknowledge that I have been advised to avoid alcohol consumption.
10. Routine urine analysis may be performed at the discretion of Dr. Edwin Maldonado.
11. Any evidence of illicit drugs found in your urine analysis testing may result in discharge from our practice.
12. If you lose your prescription, you will not receive a refill until the scheduled time of your next appointment.
13. If your prescription is stolen, a police report will be required before any additional medications are written.
14. Pharmacy miscounts are your responsibility and not that of the pharmacy or Dr. Edwin Maldonado.
15. The doctor’s office may and will call local pharmacies for confirmation of prescriptions.
16. It is the policy of the practice not to renew or prescribe pain medications after hours, on the weekend or without patient’s medical records at hand.
If any of the above requirements are not met by myself , I understand that no additional medications will be prescribed and that all of my treating physicians and pharmacies may be notified of my non- compliance. Additionally, I may be discharged from this medical practice and I may be asked to seek future pain treatment from another physician and/or undergo detoxification. I agree to the terms and conditions outlined above in this document.