North Georgia Healthcare Center



06/24/2016NORTH GEORGIA HEALTHCARE CENTER

6120 ALABAMA HWY

RINGGOLD, GA 30736

PATIENTS INFORMATION

NAME: (LAST) _________________________________ (FIRST) _____________________________ (MIDDLE) ________________

SOCIAL SECURITY NUMBER: _________-________-_________ SEX: _______ DATE OF BIRTH: _____________________________

STREET ADDRESS: __________________________________________________________________________________________

CITY: _______________ STATE: ________ ZIP: ____________ E-MAIL ________________________________________________

RACE: ______________ HISPANIC / NON-HISPANIC PUBLIC HOUSING RESIDENCE _________ # IN HOUSEHOLD __________

INCOME LEVELS: [ ] $0 - $15,000 [ ] $15,001 - $25,000 [ ] $25,001 - $35,000

[ ] $35,001 - $45,000 [ ] $45,001 - $55,000 [ ] $55,001 - $65,000

[ ] $65,001 - $75,000 [ ] $75,001 and above

MARITAL STATUS: ____________________ STUDENT: ________ SMOKER: ________ VETERAN: __________

HOME PHONE: _________________________ CELL PHONE: _________________________

WORK PHONE: _________________________ EXT: __________

EMERGENCY CONTACT: ________________________________________ PHONE: _________________________

PRIMARY INSURANCE INFORMATION

NAME OF INSURED: ________________________________________ RELATIONSHIP: _____________________

INSURED DATE OF BIRTH: __________________ SEX: ____________ INSURED SSN: _______-_______-______

INSURANCE COMPANY: __________________________________ POLICY NUMBER: ________________________

SECONDARY INSURANCE INFORMATION

NAME OF INSURED: ________________________________________ RELATIONSHIP: _____________________

INSURED DATE OF BIRTH: __________________ SEX: ____________ INSURED SSN: _______-_______-______

INSURANCE COMPANY: __________________________________ POLICY NUMBER: ________________________

|Personal Medical History |

|Instructions: Please check the boxes in each category for conditions you have currently or surgeries and conditions you have had in your lifetime. Use the blank |

|space below for adding conditions or surgeries not listed. |

Current & Past Medical Conditions / Past Surgical History

|Diabetes |Colon Cancer |Appendectomy |Hysterectomy |

|Heart Attack |Breast Cancer |Tonsillectomy |C-Section |

|Heart Failure |Lung Cancer |Cholecystectomy |Colon Bypass |

|High Blood Pressure |Prostate Cancer |Hemorrhoid Removal |Heart Bypass |

|Bronchitis/COPD |Ovarian Cancer |Breast Biopsy |Other-List Below |

|Asthma |OTHER: |HOW MANY HOSPITAL/ER VISITS HAVE YOU HAD IN THE PAST 2 YEARS? |

| | | |

| | |____________ |

|Seizure |1.HIV | |

|Liver Disease |2.TB | |

|Stroke |3.Sickle Cell | |

|Mental Trouble |4.Kidney prob. | |

|Other: | | |

|FAMILY MEDICAL HISTORY |

|Instructions: Please check the boxes indicating diagnoses that apply to immediate family members. |

| |Diabetes |Lung Cancer | |

|Mother:_____Deceased |Heart Attack |Colon Cancer | |

| |High Blood Pressure |Breast Cancer | |

|_____Age at death |Heart Failure |Ovarian Cancer | |

| |Emphysema |Others (list at right) | |

| |Diabetes |Lung Cancer | |

|Father: ______Deceased |Heart Attack |Colon Cancer | |

| |High Blood Pressure |Breast Cancer | |

|_____Age at death |Heart Failure |Ovarian Cancer | |

| |Emphysema |Others (list at right) | |

| |Diabetes |Lung Cancer | |

|Siblings: ______Deceased |Heart Attack |Colon Cancer | |

| |High Blood Pressure |Breast Cancer | |

|_____Age at death |Heart Failure |Ovarian Cancer | |

| |Emphysema |Others (list at right) | |

|_____Age at Death | | | |

|SOCIAL HISTORY |

|Instructions: Please indicate your marital status and fill in your occupation. For habits, check the line next to the substance(s) you currently use or have used |

|in the past and specify the types in the line to the right. |

| | |

|Marital Status: Single _______ Married________ |Drugs: Heroin_____ Cocaine ______ |

| | |

|Divorced_______ Widowed ______ |Methamphetamine_____ Marijuana _____ |

| | |

|Occupation: ______________________________ |Alcohol: Liquor _____ Wine _____ Beer _____ |

| | |

|Company: ______________________________ |Other: _____________ |

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|Tobacco: Cigarettes ____ Cigars_____ Pipe_____ |Drinks per week: ___________ |

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|Smokeless ________ Years Used: _____ |Date last used: _____________ |

TO ALL PATIENTS

THE PRESCRIBING OF CONTROLLED MEDICATIONS IS ALWAYS AT THE DISCRETION OF THE PHYSICIAN.

DUE TO THEIR DOCUMENTAED POTENTIAL FOR ABUSE, PHYSIOLOGIC DEPENDENCE AND ADDICTION, THEY ARE USUALLY PRESCRIBED IN SMALL NUMBERS AND FOR SHORT PERIODS OF TIME. FOR THIS REASON, MULTI-REFILL PRESCRIPTIONS WILL NOT BE PROVIDED. HAVING BEEN ON CONTROLLED MEDICATIONS FROM A PREVIOUS PHYSICIAN IS NOT AN ACCEPTABLE REASON TO CONTINUE RECEIVING SUCH PRESCRIPTIONS. IF LONG-TERM USE IS ANTICIPATED OR DEEMED NECESSARY, REFERRAL TO A SPECIALIST IN PAIN MANAGEMENT, PSYCHIATRY, OR NEUROLOGY WILL BE REQUIRED.

OUR ABILITY TO PROVIDE MEDICAL SERVICES TO OTHERS DEPENDS ON OUR LEGAL AUTHORITY TO PRESCRIBE ALL CLASSES OF MEDICATIONS. IGNORING CURRENT FEDERAL AND STATE MEDICAL REGULATIONS WILL JEOPARDIZE THIS LEGAL AUTHORITY.

CLASS II CLASS IV

METHADONE (GENERIC) ZOLPIDEM (GENERIC)

MEPERIDINE (GENERIC) BRAND: AMBIEN

BRAND: DEMEROL, MEPERGAN FLURAZEPAM (GENERIC)

HYDROMORPHONE (GENERIC) BRAND: DALMANE

BRAND: DILAUDID TRIAZOLAM (GENERIC)

FENRTANYL (GENERIC) BRAND: HALCION

BRAND: DURAGESIC ESTAZOLAM (GENERIC)

MORPHINE (GENERIC) BRAND: PROSOM

BRAND: KADIAN, MsCONTIN, TEMAZEPAM (GENERIC)

ORAMORPH, MSIR, BRAND: RESTORIL

ROXANOL, AVINZA LORAZEPAM (GENERIC)

OXYCODONE (GENERIC) BRAND: ATIVAN

BRAND: PERCOCET, OXYCONTIN, CLONAZEPAM (GENERIC)

ENDOCET, PERCODAN BRAND: KLONOPIN

METHYLPHENIDATE (GENERIC) CHLORDIAZEPOXIDE (GENERIC)

BRAND: RITAKUN, METADATE BRAND: LIBRIUM

DEXATROAMPHETAMINE (GENERIC) OXAZEPAM (GENERIC)

BRAND: ADDERALL, DEXEDRINE BRAND: SERAX

HYDROCODONE (GENERIC) CLORAZEPATE (GENERIC)

BRAND: VICODIN, VICOPROFEN BRAND: TRANXENE

LORATAB, LORCET, NORCO DIAZEPAM (GENERIC)

CLASS III BRAND: VALIUM

APLPRAZOLAM (GENERIC)

CODEINE: (GENERIC) BRAND: XANAX

BRAND: TYLENOL #2, #3, #4 SPECIAL CLASS IN GEORGIA

BUTALBITAL (GENERIC)

BRAND: FIORICET, ESGIC CARISOPRODOL (GENERIC)

BRAND: SOMA

I HAVE READ AND ACKNOWLEDGE THE ABOVE POLICY:

PATIENT SIGNATURE: ________________________________________ DATE: _________________

DATE OF BIRTH: _________________________

NORTH GEORGIA HEALTHCARE CENTER

6120 Alabama Hwy / P.O. Box 729 / Ringgold GA 30736

Phone: 706 935-6442 Fax: 706 935-6441

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

|Patient’s Name: | |Date of Birth: | |

|Previous Name: | |Social Security #: | |

|I request and authorize | |to |

|release healthcare information of the patient named above to: |

| |Name: |North Georgia Healthcare Center |

| |Address: |P.O. Box 729 |

| |City: |Ringgold |State: | GA |Zip Code: | 30736 |

|This request and authorization applies to: |

|( Healthcare information relating to the following treatment, condition, or dates: | |

| | |

|( All healthcare information |

|( Other: | |

| |

|Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, |

|genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), |

|AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea. |

| |

|( Yes ( No |I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) |

| |listed above. I understand that the person(s) listed above will be notified that I must give specific written |

| |permission before disclosure of these test results to anyone. |

| |

|( Yes ( No |I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) |

| |listed above. |

|Patient Signature: | |Date Signed: | |

| |

| |

|THIS AUTHORIZATION IS GOOD UNTIL REVOKED BY PATIENT IN WRITING. |

PATIENT AUTHORIZATION FOR RELEASE OF INFORMATION

TO FAMILY AND / OR FRIENDS

Name of Patient: ______________________ Date of Birth: _______________

North Georgia Healthcare Center (NGHCC) is authorized to release protected health information about the above named patient to the entities named below.

Entity to Receive Information. Initial each that is subject to this authorization.

Give information to following person(s):___________________________________

Description of Information to be released.

____ Financial information.

____ Family billing information.

____ Information results from tests or x-rays.

____ Medical information as follows: __________________________________

__________________________________________________________

Other information as described: _________________________________

__________________________________________________________

Rights of the Patient

I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document by sending a written notification to NGHCC.

I understand that information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing this authorization.

This Authorization shall be in force and effect until revoked by the patient or representative signing the Authorization.

____________________________________ Date: _________________

Signature of Patient or Representative

Description of Personal Representative’s Authority (attach necessary document)

PATIENT ACKNOWLEDGMENT OF UNDERSTANDING REGARDING

North Georgia Healthcare Center PRIVACY PRACTICES

Patient’s Name: _____________________ DOB: __________________

SSN#:_____-____-______ Previous Name(s):______________________

I understand the patient’s health information is private and confidential. I understand that NGHCC works very hard to protect the patient’s privacy and preserve the confidentiality of the patient’s personal health information.

I understand NGHCC may use and disclose the patient’s personal information to help provide health care to the patient, to handle billing and payment, and to take care of other health care operations. In general, there will be no other uses and disclosures of this information unless I permit it. I understand that sometimes the law may require the release of this information without my permission.

NGHCC possesses a detailed document called “Notice of Privacy Practices.” It contains more information about the policies and practices protecting the patient’s privacy and it attached to this Acknowledgment. I understand that I have the right to read the “Notice” before signing this Acknowledgment.

NGHCC may update this Acknowledgment and “Notice of Privacy Practices.” If I ask, NGHCC will provide me with the most current “Notice of Privacy Practices.”

Within this “Notice of Privacy Practices” is a complete description of my privacy/confidentiality rights. These rights include, but aren’t limited to, access to my medical records; restrictions on certain uses; receiving an accounting of disclosures as required by law and requesting communication be by specified methods of communication or alterative action.

NGHCC’s established procedures help it meet its obligations to patients. These procedures may include other signature requirements, written acknowledgments, and authorizations; reasonable time frames for requesting information; charges for copies and non-routine information needs; etc. I will assist NGHCC by following these procedures if I choose to exercise any of my rights described in the “Notice of Privacy Practices.”

My signature below indicates that I reviewed a current copy of NGHCC’s “Notice of Privacy Practices.”

__________________________________ Date: __________ Time: ________

Signature

__________________________________________________________________

Relationship to patient if signed by anyone other than the patient,

(Parent, legal guardian, personal representative, etc.)

CONSENT TO TREATMENT/FINANCIAL RESPOSIBILITY

ALL PATIENTS MUST SHOW THEIR INSURANCE OR MANAGED CARE MEMBERSHIP CARD, AND CURRENT VALID STATE ISSUE PHOTO ID, SO THAT NGHCC MAY MAKE COPIES FOR THE PATIENT RECORD.

I CONSENT TO TREATMENT NECESSARY FOR THE CARE OF (patient name)

___________________________.

_____________________________ __________________________

Print Name Signature

OR, IF PATIENT IS A MINOR OR LEGALLY INCOMPETENT:

_____________________________ __________________________

Print Name Signature of (parent or guardian)

FINANCIAL ARRANGEMENTS:

AT THE TIME OF SERVICE, YOU, THE PATIENT, ARE RESPONSIBLE FOR YOUR PERCENTAGE (I.E., “CO-PAYMENT”) PLUS ANY DEDUCTIBLE. IF YOUR INSURANCE COMPANY DOES NOT PAY WITHIN 90 DAYS FROM THE INITIAL DATE OF TREATMENT THEN THE FULL BALANCE AT THAT TIME IS YOUR RESPONSIBILITY.

I ACKNOWLEDGE FULL FINANCIAL RESPONSIBILITY FOR SERVICES RENDERED BY NGHCC FOR THE ABOVE NAMED PATIENT:

Signature: _________________________________________________________

Last Name First Middle

Social Security#:_________________________

Relationship to Patient: ____________________

Address: ________________________________

City: _____________________ State: _______________ Zip: __________

I AGREE TO PAY ALL REASONABLE ATTORNEYS’ FEES, INTEREST, PREJUDGMENT COLLECTION COSTS AND LITIGATION COSTS IN THE EVENT NGHCC FAILS TO RECEIVE PAYMENT IN FULL FOR THE COSTS OF MY MEDICAL TREATMENT. _____ (Initial)

ALL ACCOUNTS ARE DUE AND PAYABLE NO LATER THAN NINETY (90) CALENDAR DAYS FROM DATE OF SERVICE. I HEREBY AGREE TO A FINANCE CHARGE OF ONE (1%) PERCENT PER MONTH, (12% PER YEAR), ON ALL PAST DUE ACCOUNTS. _____ (Initial)

I FURTHER AUTHORIZE AND DIRECT THAT INSURANCE PAYMENTS SHALL BE MADE DIRECTLY TO NGHCC. _____ (Initial)

I READ AND FULLY UNDERSTAND THE ABOVE CONSENT & ACKNOWLEDGMENT OF TREATMENT CONDITIONS, FINANCIAL RESPONSIBILITY, RELEASE OF MEDICAL INFORMATION, AND INSURANCE AUTHORIZATION. _____ (Initial)

_______________________________ _____________________

Signature Date

6120 Alabama Hwy, Ringgold GA30736 CARDIOVASCULAR RISK QUESTIONNAIRE

P: 706-935-6442

NAME: ______________________________ EMAIL ADDRESS: __________________________________

ADDRESS: ______________________________________________________________________________________

PHONE # :____________________________DOB: _____________ Please Circle : MALE or FEMALE

CARDIOVASCULAR DISEASE: THE NUMBER ONE KILLER

Cardiovascular Disease is the biggest cause of death in the United States, with one person dying from it every 53 seconds. That’s over 597,000 people per year dying from heart attacks, strokes and blood clots.

WHAT IS CARDIOVASCULAR DISEASE?

Cardiovascular disease is the accumulation of fat in the arteries. This fat can cause blood clots to form and if large enough can completely block a blood vessel. When a clot blocks a blood vessel that is feeding the heart, part of the heart will die. This is called a heart attack. If a clot blocks a blood vessel connected to the brain, part of the brain will die, and this is called a stroke.

WHAT CAUSES CARDIOVASCULAR DISEASE?

Most people know that high cholesterol and blood pressure contribute to your risk of a heart attack. Knowing your cholesterol level and blood pressure is an important step in reducing your risk. However 50% of people who have heart attacks don’t have high cholesterol or high blood pressure. There are other important factors that can increase your risk of cardiovascular disease. You may have risk factors which haven’t been measured by your doctor. For example you may be under stress, not doing enough exercise, have poor immune function or be eating too much sugar. These are just a few of the many factors that may cause cardiovascular disease.

HOW DO I REDUCE MY RISK OF CARDIOVASCULAR DISEASE?

To reduce your risk of cardio0vascular disease you need to know what may be putting you in danger and what you can do about it. This questionnaire will help identify your risk of cardiovascular disease and allow you and your healthcare provider to decide on the most appropriate dietary changes, lifestyle changes or supplements to help you maintain a healthy heart and blood vessels.

PLEASE CIRCLE THE FOLLOWING ANSWERS TO THE QUESTIONS

FAMILY HISTORY:

How many hospital/ER visits have you had in the past 2 years? ____________

Has anyone in your family had a heart attack or die suddenly before the age of 60? YES NO

Has a physician ever told you that you had a heart attack or have angina? YES NO

Has a physician ever told you that you had a stroke or have partially blocked blood flow to your head or legs? YES NO

Has a physician ever told you that you have diabetes? YES NO

Do you currently smoke? YES NO Amount per day? ____________________

How many times per week do you engage in aerobic exercises of a least 30 min duration?

NO REG EXERCISE ONCE PER WEEK TWICE PER WEEK THREE TO FOUR PER WEEK FIVE OR MORE PER WEEK

Indicate the kind of foods you usually eat:

HIGH SATURATED FAT FOODS: RED MEATS, WHOLE MILK, CREAM, BUTTER, CHEESE, CREAMY DRESSING, GRAVIES, FAST FOODS, DESSERTS, DEEP FRIED FOODS

LOW SAUTRATED FAT FOODS: SKIM MILK, LOW FAT DAIRY PRODUCTS, BREADS, CEREALS, FRUITS, VEGGIES, PEAS, BEANS, FISH, AND SKINLESS POULTRY

STAFF USE:

HEIGHT__________ WEIGHT _________ BMI ___________ BLOOD PRESSURE ______________ PFT _____________

LIPO/TRI ____________ GLU ___________ A1C___________ CBC ________ _ CMP____________

Tobacco Use Assessment Form

Name: _________________________ Date: _______________ MR#: _____________

1. Have you ever smoked cigarettes or used any other tobacco product?

_____YES _____NO

2. Do you currently smoke cigarettes or use any other tobacco product?

_____ YES _____NO – Date stopped ______________

If you answered YES to questions 1 or 2, please answer the following:

Type of tobacco:____________________

Length of use (months or years):____________________

Amount used per day on average:____________________

3. Does anyone you live with or who is close to you smoke cigarettes or use other forms of tobacco?

_____ YES _____NO

Continue only if you answered YES to #2

4. How soon after you wake up do you smoke your first cigarette or use other forms of tobacco?

_____ within 30 minutes

_____ more than 30 minutes

5. How interested are you in stopping smoking or stopping use of other forms of tobacco?

_____ not at all

_____ a little

_____ some

_____ very

6. If you decided to quit smoking or using other forms of tobacco completely during the next 2 weeks, how confident are you that you would succeed?

_____ not at all

_____ a little

_____ some

_____ very

7. Have you ever intentionally quit smoking/using other forms of tobacco for 24 hours or longer?

_____ YES

_____ NO

In the past year? _____ YES _____ NO

In the past month? _____YES _____NO

Since the last visit? _____YES _____NO

Patient Health Questionnaire - 2 for MR#____________

|Over the last 2 weeks, how often have you been bothered by either of the following? (use a "|Not at all |Several days |More than half the|Nearly every day |

|" to indicate your answer) | | |days | |

|Little interest or pleasure in doing things | | | | |

|Feeling down, depressed, or hopeless | | | | |

Are you wanting a pregnancy or prevent a pregnancy? ____ wanting ____ prevent

Do you want this visit to be confidential? ____yes ____no

What form of prevention have you used in the past or are currently using?

| Female sterilization ______ Hormonal Implant _____ 1-Month hormonal injection _____ |

| 3-Month hormonal injection _____ Oral contraceptive _____ Contraceptive patch _____ |

| Vaginal ring _____ Cervical cap or diaphragm _____ Contraceptive sponge _____ |

| Female condom _____ Spermicide - used alone _____ Abstinence _____ Male condom _____ |

| Withdrawal or other method _____ Rely on Male Method Vasectomy _____ |

| FAM or LAM - Fertility awareness or lactational amenorrhea method _____ |

| No method Pregnant/seeking pregnancy _____ Unknown/Not reported _____ |

|Have you had any sexually transmitted disease or testing? _____ yes _____ no __________ when? |

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|Chlamydia _____ Gonorrhea _____ Syphilis _____ |

| |

|Have you ever had an HIV test? _____ yes _____ no __________ when? |

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|PAIN MANAGEMENT/CONTROLLED SUBSTANCE AGREEMENT |

| |

|PATIENT: _________________________________________________ DOB:________________________ |

| |

|The purpose of this Agreement is to prevent misunderstandings about certain medicines you will be taking for pain management or controlled |

|substance such as anti-anxiety medication (Example-Valium, Xanax) or ADD/ADHD medications. This is to help both you and your doctor to comply |

|with the law regarding controlled pharmaceuticals. |

|_______ PT INITIALS |

| |

|I understand this Agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my doctor undertakes to|

|treat me based on this Agreement. |

|_______ PT INITIALS |

| |

|Because these medicines have the potential for abuse or diversion, strict accountability is necessary. |

|MEDICATION(S) _______________________________ _________________________________ |

| |

|__________________________________ ___________________________________ |

| |

|I understand if I break this Agreement, my doctor will stop prescribing this pain-control medications/controlled substances. |

|_______ PT INITIALS |

| |

|I agree to notify my doctor of any and all pain medications or prescriptions I have received from other providers (effective from date of this |

|agreement and ongoing). Such notification should occur by next business day following receipt of prescription. If I fail to alert my doctor I |

|understand I may be discharged from the practice. _______ PT INITIALS |

| |

|I understand at some point my doctor may wean me partially or totally from narcotics if he/she determines that, in the long run, this is likely |

|to be in my best interests. In such situations other meds or therapies will likely be suggested as part of my new treatment plan. I agree to |

|respect my doctor's opinion in such circumstances and comply with the new treatment plan. |

|________ PT INITIALS |

| |

|I understand if I am suspected of diverting or distributing my pain medications/controlled substances, my doctor will immediately cease |

|prescribing these medications. In this case, my doctor will be required to comply with local state and/ or federal reporting requirements and |

|investigation. |

|________ PT INITIALS |

| |

|I would also be amenable to seeking psychiatric treatment, psychotherapy and/or psychological treatment if my doctor deems necessary. |

|_____ PT INITIALS |

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|I agree to communicate fully and honestly with my doctor about the character and intensity of my pain, the effect of the pain on my daily life, |

|and how well the medicine is helping to relieve the pain. |

|________ PT INITIALS |

|If the medication causes drowsiness, sedation, or dizziness, I understand that I must not drive a motor vehicle or operate machinery that could |

|put my life or someone else's life in jeopardy. I also understand that my state may have regulations concerning driving while under the |

|influence of drugs and accept responsibility for adhering to those regulations. |

|_______ PT INITIALS |

| |

|I understand the use of opiates or pain medications in combination with anti-anxiety medications such as Valium or Xanax may cause me to stop |

|breathing and abnormal heart rhythms resulting in injury or death. |

|_______ PT INITIALS |

| |

|I understand strong medications, which may include opiates and other controlled substances, which I may be prescribed , have potential risks and|

|side effects, including the risk of addiction. An over-dosage with an opiate medication may cause injury or death. Other possible complications |

|include, but are not limited to, constipation, difficulty with urination, fatigue, drowsiness, nausea, itching, stomach cramps, loss of |

|appetite, confusion, sweating , flushing, depressed respiration, and reduced sexual function. |

|_______ PT INITIALS |

| |

|I will not use any illegal controlled substances or illegal street drugs, including marijuana, cocaine, etc., nor will I misuse or |

|self-prescribe/medicate with legal controlled substances. Use of alcohol will be limited to a time when I am not driving, operating machinery |

|and will be infrequent . |

|_______ PT INITIALS |

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|I will not share, sell or trade my medication with anyone. |

|_______ PT INITIALS |

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|I will not attempt to obtain any controlled medicines, including opioid pain medicines, controlled stimulants, or anti-anxiety medicines from |

|any other doctor. |

|_______ PT INITIALS |

| |

|I will inform my doctor of ALL current medications including herbs, vitamins, supplements, and over-the-counter medications. I will provide an |

|updated medication list during every visit. |

|_______ PT INITIALS |

| |

|I will not alter my medicine in any way or use any other administrative method other than what has been prescribed. |

|Long-term agents (MS Contin, Oxycontin, etc.) must be taken whole and are not allowed to be broken, chewed, crushed, injected and/or snorted. |

|Potential toxicity could occur due to rapid absorption if taken inappropriately, which may lead to death. |

|_______ PT INITIALS |

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|I understand suddenly stopping some medications (including opioids and sedatives) can cause substantial discomfort over and above any increase |

|in my chronic pain causing psychological distress, extreme achiness, fatigue, nausea, and trembling, etc. |

|_______ PT INITIALS |

| |

|I will avoid withdrawal symptoms by budgeting my pills, not taking more medications than prescribed, and keeping my appointments for refills. I |

|understand that "running out " of medication in itself is not grounds for insisting on an "emergency or urgent appointment". |

|_______ PT INITIALS |

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|I will safeguard my pain medicine/controlled substances from loss or theft. Lost or stolen medicines will not be replaced. |

|_______ PT INITIALS |

|I agree that refills of my prescriptions for pain medicine/controlled substance will be made only at the time of an office visit or during |

|regular office hours. No refills will be available during evenings or on weekends. |

|_______ PT INITIALS |

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|I agree that prescriptions for pain medicine/ controlled substances will not be refilled earlier than the agreed upon renewal date. |

|_______ PT INITIALS |

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|(MALES ONLY) I am aware that chronic opioid use has been associated with low testosterone levels in males. This may affect my mood, stamina, |

|sexual desire and physical and sexual performance. I understand my prescriber/provider may check my blood or request my primary care provider |

|do routine testing to see if my testosterone level is normal. Please be aware your insurance may not cover this test, therefore if deemed |

|medically necessary you agree to be responsible for any costs not covered by your insurance. |

|_______ PT INITIALS |

| |

|(FEMALES ONLY) If I plan to become pregnant or believe I have become pregnant while taking this medication, I will immediately call my obstetric|

|doctor and prescribing prescriber/ provider 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. Infant drug withdrawal can be life threatening. If a female of childbearing age, I certify |

|that I am not pregnant and will use appropriate contraceptive measures during the course of treatment with opioids/controlled substances. |

|_______ PT INITIALS |

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|I agree to use____________________________________________________________Pharmacy, Located at |

|_______________________________________________________________________ |

|Telephone Number _____________________________, for filling prescriptions for all of my pain |

|Medicine/controlled substance. I agree to notify my provider within 48 hours should I change |

|my pharmacy. |

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|If I chose to have my medications filled by a new pharmacy not listed above, I will be required to sign an amendment to this agreement with my |

|updated pharmacy information. |

|_______ PT INITIALS |

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|I understand changing date, quantity, or strength of medicines or altering a prescription in any way is against the law. Forged prescriptions |

|and/or forged provider's signatures are also against the law. If any of these instances occur, it will result in an immediate termination from |

|this practice. |

|_______ PT INITIALS |

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|I authorize the doctor and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state's Board |

|of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medicine or other controlled substances. I |

|authorize my doctor to provide a copy of this Agreement to my pharmacy. I agree to waive any applicable privilege or right of privacy or |

|confidentiality with respect to these authorizations. |

|_______ PT INITIALS |

| |

|I agree I will submit to a blood or urine test if requested by my doctor to determine my compliance with my program of pain control |

|medicine/controlled substance. Tests may include screens for illegal substances. I also understand I may be selected for random drug testing as |

|if selected I must report to the office within 24 hours. I understand refusal of such testing may result in an abrupt/rapid wean schedule in |

|order for the medication to be discontinued or prompt termination from care. |

|_______ PT INITIALS |

|I agree I will use my medicine at a rate no greater than the prescribed rate and that use of my medicine at a greater rate will result in my |

|being without medication for a period of time. |

|_______ PT INITIALS |

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|I will bring all unused pain medicine or controlled substance to every office visit related to the management of my pain treatment program. |

|_______ PT INITIALS |

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|I understand any serious misbehavior such as yelling, threatening, cursing, etc will likely be cause for dismissal from the practice. |

|_______ PT INITIALS |

| |

|I agree to follow the guidelines that have been fully explained to me. All of my questions and concerns regarding treatment have been adequately|

|answered. A copy of this document has been given to me. |

|_______ PT INITIALS |

| |

|Date: _____________ |

| |

|Patient Signature_____________________________________________________ |

| |

|Prescriber/Provider Signature: __________________________________________ |

| |

|Witnessed By: ________________________________________________________ |

| |

|I authorize the following individual(s) to pick up my prescription(s) in the event I am unable to do so. I understand that this individual(s) |

|must provide a picture ID and sign for the prescription(s) before it will be released. I understand my prescription(s) will not be released to |

|anyone other than those listed below. |

| |

| |

|1.______________________________________/Relationship_____________________________ |

| |

| |

|2._______________________________________/Relationship____________________________ |

| |

| |

|3._______________________________________/Relationship____________________________ |

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