PLEASE READ THE WHOLE FORM
NOTE: THIS FORM IS ONLY FOR PATIENTS WHO ARE ALREADY ON OR WILL BE PRESCRIBED NARCOTIC PAIN MEDICATIONS.
FIRST MIDDLE LAST
CONSENT AND AGREEMENT FOR CHRONIC NARCOTIC MEDICATION
I am signing this agreement for regularly scheduled narcotic medication for pain control. I understand that my condition or diagnosis causes me chronic intractable pain.
The purpose of this consent is to protect my access to controlled substances and to protect Dr. Zahl's ability to prescribe for me.
The long-term use of such substances as opiates (narcotic analgesics), benzodiazepine tranquilizers, and other sedatives are controversial because of uncertainty regarding the extent to which they provide long-term benefit. There is also the risk of an addictive disorder (psychological dependence/physical dependence) developing or of relapse occurring in a person with a prior addiction. The percent of this risk is not certain.
Because these drugs have the potential for abuse or diversion, strict accountability is necessary when use is prolonged. For this reason the following policies are agreed to by me, the patient, as consideration for, any condition, the willingness of the physician and/or physician assistant whose signature appears below to consider the initial and/or continued prescription of controlled substances to treat my chronic pain.
I am asking for chronic narcotic pain medication because other treatments and medications I have received have not controlled my pain. It is unlikely that any medication will completely take away my pain, but for humane reasons narcotic pain medication will be given to me as long as my pain continues, provided that I follow the terms of this agreement.
I understand that the possible complications of chronic narcotic therapy include chemical dependence, addiction, constipation that could be severe enough to require medical treatment, difficulty with urination, drowsiness, nausea, itching, depressed respirations, and reduced sexual function. If I take more medication than what is prescribed a dangerous situation could result, such as coma, organ damage or even death. I understand that if I run out of my medication too soon, or if my medication is stopped suddenly that I could have narcotic withdrawal symptoms, which can be very uncomfortable or dangerous. I also understand that death due to overdose or mixing my narcotic with alcohol, other dangerous drugs such as cocaine, uppers or downers can and does frequently occur.
The alternative to this kind of medication is to continue using non-habit forming medications or other types of pain treatment not involving medications, although even though no form of treatment may ever completely take away the pain. It is hoped that I will eventually become better to cope with my chronic pain, whether or not I am taking medication. By signing this consent I am agreeing to the following terms:
1. Only Dr. Kenneth Zahl or a designated covering physician or licensed practitioner will prescribe narcotic pain medication for me. I am not permitted to get such medication from any other doctor or clinic. By typing my name at the end of this form I understand and agree to this all the terms below.
2. A psychological or psychiatric evaluation may be performed before this agreement can go into effect, or at any time Dr. Zahl feels it is necessary, and/or if Dr. Zahl refers me to an addiction specialist for a second opinion I agree to be so evaluated.
3. I agree to random drug testing at the initiation of treatment, and whenever Dr. Zahl feels necessary to monitor the effects of these medications or check compliance
4. A daily dosage will be chosen. Any adjustments in the dose including increases in dosage will not be considered or permitted until I am re-evaluated by Dr. Zahl or a covering physician, or licensed practitioner. I understand that it is not possible for this medication to completely take away pain on a long-term basis and I understand that narcotics may have less and less effect on pain when used for a long time. I have also been informed of a condition called opioid induced hyperalgesia, which develops when high doses of narcotics are used, that in this case the higher dose of narcotic paradoxically worsens my perception of pain.
5. The use of this medication will be strictly monitored, and will sent electronically to a pharmacy of my choice but must be electronically enabled. If I run out of medication early because I have been taking more than the correct amount. In the event new injury occurs the hospital or I will immediately call or securely message Dr. Zahl - but extra medication will not automatically be given if no contact is made. Lack of planning on my part does not constitute an emergency on his practice. Absolutely no calls or walk-ins for unplanned or emergency medication refills will be taken if the agreement is violated. If I develop a new injury or pain problem and am given narcotic pain medicine for this, the prescribing doctor must confirm this with Dr. Zahl. Dr. Zahl reserves the right to charge for phone and follow-up calls related to calls for lack of planning.
6. Any altered or forged prescriptions, any prescriptions I might get from doctors other than Dr. Zahl or a covering doctor. (Unless specifically authorized by Dr. Zahl), or any attempt to sell or give my medication to somebody else will cause this agreement to be canceled. If this happens, Dr. Zahl after reviewing the circumstances, may reduce and/or stop my medication and may not give me any more narcotic pain medication, or I may be referred to another physician or hospital. Likewise, If I am getting absolutely no help from this medication, or if there are other medical problems, Dr. Zahl may need to slowly reduce and/or stop the narcotic. I understand it may be necessary for me to enter a chemical dependence (addiction) program in order to take me completely off the medication.
7. I must return to be seen by Dr Zahl at least every three months, or monthly, or as he directs. If I have not been seen in over three months, or if I missed a scheduled appointments this agreement is voided.
8. I am expected to inform his office of any new medications or medical conditions, and of any adverse affects experienced from any of the medications that I take.
9. The use of medications is not designed to completely eliminate the pain, rather the medication is used to significant reduce pain so that the individual may be able to perform many activities of daily living as well as social activities. It is hoped that the use of these medications will improve the quality of life but is not expected that the pain relief will be complete.
10. I know that the Narcotics prescribed for me may not be shared, sold, traded, exchanged for for money, goods, services, etc. or otherwise permit others to have access to these medications.
11. I agree to keep these medications in a secure place preferably a safe. Since the drugs may be hazardous or lethal to a person that is not tolerant to its affects, especially a child or pet, I must keep them out of the reach of other people or pets.
12. Prescriptions and bottles of these medications may be sought by individuals with chemical dependency and should be closely safeguarded. It is expected that your will take the highest possible degree of care with your medication and prescription. They should not be left where others might see or otherwise have access to them. I will not attempt to get pain medications from any other health care provider without telling them that I am taking pain medications prescribed by the Dr. Zahl.
13. Dr Zahl, my prescribing physician has permission to discuss all diagnostic and treatment details with dispensing pharmacist or other professionals or clinics/hospitals who provide my health care.
14. Unannounced, random urine, saliva or serum toxicology screens may be requested by DR. ZAHL OR COVERING PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER to determine my compliance with this agreement and my regimen of pain control medication. Tests may include screens for illegal substances, and full cooperation is required. Presence of unauthorized substances may prompt referral for assessment for addictive disorder. Refusal of such testing may subject you to an abrupt rapid wean schedule in order for the medication to be discontinued or prompt termination from care.
15. I realize that is my responsibility to keep others and myself from harm, this includes the safety of my driving and the operation of machinery. If there is any question of impairment of my ability to safely perform any activity, I will not attempt to perform the activity until my ability to perform the activity has been evaluated or I have stopped the medication long enough for the side affects to resolve. This applies to all medications prescribed by DR. ZAHL OR COVERING PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER.
16. I will not use any illegal substances (cocaine, heroin, bath salts, spice, crystal meth., ecstasy, ketamine, etc.) while being treated with controlled substances. Violation of this is likely to result in the cessation of the prescribing of any controlled substances and termination of care.
17. I will not alter my medication in any way (for example crushing or chewing tablets) or use any other auto-delivery (for example injection on insufflation) other then as prescribed by DR. ZAHL OR COVERING PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER.
18. Long-term agents (MS Contin, Oxycontin, Oramorph, Kadian, Avinza, etc.) must be taken whole and are not allowed to be broken, chewed, crushed, injected, snorted. Potential toxicity could occur due to rapid absorption if taken inappropriately, which often times may lead to death.
19. I understand that changing date, quantity or strength of medications or altering a prescription in any way, shape or form is against the law. Forged prescriptions or the providers signature is also against the law. Similarly seeing another pain physician or getting narcotics from any other un-authorized physician DR. ZAHL OR COVERING PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER cooperates fully with law enforcement agencies locally as well as the Drug Enforcement Agency (DEA) in regards to infractions involving prescription medications. If there is a law violation this will be reported to the patient's pharmacy, private physicians, local authorities and DEA.
20. I understand that strong medications, which may include opiates and other controlled substances may be prescribed for pain relief. I understand that there are potential risks and side affects with taking any medications, including the risks of addiction. Overdose of opiate medication may cause injury or death by stopping breathing. This may be reversed by emergency personnel if they know I have taken opiate pain killers. It is suggested that I wear a medical alert bracelet or necklace that contains this information. Other possible complications include, but are not limited to, constipation which could be severe enough to require medical treatment, difficulty with urination, fatigue, drowsiness, nausea, itching, stomach cramps, loss of appetite, confusion, sweating, flushing, depressed respiration, and reduced sexual function.
21. I realize that all medications have potential side affects and interactions. I understand and accept that there may be unknown risks associated with the long-term use of substances prescribed.
22. I understand that any medical treatment is initially a trial, in that regard continued narcotic prescriptions is contingent on evidence of benefit and my strict compliance.
23. Endocrine Problems please read carefully:
24. Males on chronic opioid will develop low testosterone (the male sex hormone) levels in males. This may obviously affect my mood, stamina, sexual desire, physical and sexual performance AND WORSEN MY PERCEPTION OF PAIN. I understand that my physician may check my blood or request that my primary care provider do routine testing to see if my testosterone level is normal.
25. Females on chronic opioid use will develop low estrogen (the female sex hormone) levels and lower testosterone levels (also needed by women. This may obviously affect my mood, stamina, sexual desire, physical and sexual performance AND WORSEN MY PERCEPTION OF PAIN. If I plan to become pregnant or believe that I have become pregnant while taking this medication, I will immediately call my obstetric doctor and/or primary care provider and DR. ZAHL office to inform them. I am aware that, should I carry a baby to delivery while taking these medications, the baby will be physically dependent upon opioids. I am aware that the use of opioids is not generally associated with the risk of birth defects. However, birth defects can occur whether or not the mother is on medications and there is always the possibility that my child will have a birth defect while I am taking opioids. The child could be physically dependent on the opiates and withdrawal can be life threatening for a baby. If a female of child-bearing age, I certify that I am not pregnant and will use appropriate contraceptive measures during the course of treatment with medications from DR. ZAHL OR COVERING PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER. FOLLOW-UP EVALUATIONS or NARCOTIC REFILLS (Refill is a misnomer - as each prescription requires a new visit and evaluation)
26. Prescriptions will not be automatically phoned in after hours, on weekends or holidays with rare exceptions. Lack of planning on my part does not make it an EMERGENCY on Dr. Zahl or his staff.
27. Timely request for refills of medications are solely the patient's responsibility. I agree to adhere to the DR. ZAHL OR COVERING PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER's prescription refill re-evaluation policy.
28. I agree that I will use my medication at a rate not greater than the prescribed rate unless it is discussed directly with a DR. ZAHL OR COVERING PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER prescriber/physician.
29. Dr Zahl or covering provider will be the only one to decide when and how I am increase or decrease various pain medications. If the provider decides to discontinue the use of pain medicine, the provider will follow the patient through a tapering off period, or change to alternate drug such as suboxone or methadone.
30. Early refills OR prescriptions will not be given absent a valid reason. The patient is responsible for taking the medications as prescribed. No unauthorized increase in medications will be tolerated, rather than running the risk, please contact us if there is a new injury or worsening of the pain, rather than changing the medication on your own.
31. Refill or Routine Follow-up appointments will not be made as an emergency unless there are extenuating circumstances. There is a 6 business day minimal request to request medication/prescription refills or re-evaluations.
32. Changes in prescriptions/refills should be made only during scheduled appointments and occasionally via phone during normal office hours. Unless a bona fide emergency do not call at night, on weekends or holidays. Due to the volume of calls, not calls can be returned until the next office opening. This policy will be strictly adhered to.
DRUG RELATED QUESTIONS
PLEASE PICK ONE
Please pick one
This consent and agreement, along with the required, NON-DISCLOSURE AGREEMENT, have been read and understood by me, and I understand and agree to all of the above terms and conditions. I understand that this agreement is enforceable and legally binding, once I finish reading and enter my name and date below, and that an electronic copy will be saved in my patient record. I understand I can also print or store my own copy for my records or to bring to the office to discuss further.
WARNING: YOU MUST CLICK "SUBMIT FORM" AND SEE A MESSAGE IN GREEN STATING "SUCCESSFULLY SUBMITTED" BEFORE GOING TO THE NEXT FORM OR THE ENTIRE FORM WILL BE LOST
