MEDICAL AGREEMENT (pdf format)

The purpose of this agreement is to protect your proper use of controlled substances and to protect our ability to prescribe for you. Furthermore, this agreement is to assure a patient/physician relationship based on the need to serve and comply with the city, state and federal laws and regulations regarding the appropriate use of controlled pharmaceuticals. Associated risks of opioid (narcotic) medications include risk of an addictive disorder developing or of relapse with a prior addiction. Other potential risks may include: falls, sedation, osteoporosis, endocrine problems and others. The extent of these risks are not certain. Because these drugs have potential for abuse or diversion, strict accountability is necessary.

For these reasons the following policies are agreed to by you, the patient, as consideration for, and a condition of, the willingness of Dr. Manish Suthar whose signature appears below to consider the initial and/or continued prescription of controlled substances. I understand that if I fail to comply with this agreement, our medical staff has the right to discontinue providing prescriptions. If discontinuation is necessary, you will be tapered off the medicines over a period of several days to avoid withdrawal symptoms.

1. All controlled substances must come from only our office, unless specific authorization is obtained for an exception. (Multiple sources can lead to unwanted drug interactions or poor coordination of treatment.)
2. All controlled substances must be obtained at the same pharmacy. Should the need arise to change pharmacies, our office must be informed.
3. Our office has permission to discuss all diagnostic and treatment details with dispensing pharmacists or other professionals who provide your health care for purposes of maintaining accountability.
4. These medications should not be stopped abruptly.
5. Random urine or serum toxicology screens may be requested. Presence of illegal or inappropriate substances may prompt referral for addictive disorder and/or discharge from our office.
6. You may not share, sell, or otherwise permit others to have access to these medications.
7. Prescriptions and bottles may be sought by others with chemical dependency and should be closely safeguarded. It is your responsibility to take the highest possible degree of care with your medication and prescription. Keep medications in a secure and locked place.
8. Since the drugs may be hazardous or lethal to CHILDREN, you are strongly recommended to keep these medications in a fire-proof safe locked case.
9. Original containers of medications and medications should be brought in to each office visit.
10. Please do not adjust the dose on your own; do not take more than prescribed.
11. Medications will not be replaced if they are lost, get wet, are destroyed, left on an airplane, etc. If your medication has been stolen and you complete a police report regarding the theft and forward to our office.
12. Refills only by scheduled appointments; no refills over the phone. Please do not phone for prescriptions after- hours or on weekends. Early refills will generally not be given.
13. Do not tamper with medications (crush, break or modify).
14. Please understand that any medical treatment is initially a trial, and that continued prescription is contingent on evidence of benefit.
15. DO NOT DRINK ALCOHOL WITH OPIOIDS, NO EXCEPTIONS.
16. POISON HOTLINE: 800-222-1222. MEDICATION DISPOSAL: WWW.DAILYMED.COM