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Call: 1 (775) 689-5410
Home
Our Team
Services
About
Conditions Treated
Treatments Options
Physical Therapy
Diagnostic Tools
Referring Physicians
Patients
New Patients
Patient Resources
Insurance Information
Forms
Contact
Patient Portal
Medication Agreement 2022
Comprehensive. Committed. Compassionate.
Step
1
of
3
33%
PRESCRIPTION MEDICATION AGREEMENT
Controlled Substance Treatment of Pain
Patient:
(Required)
DOB
(Required)
MM slash DD slash YYYY
Patient #:
(Required)
Patient Email
(Required)
Nevada Law requires a patient to enter a
“Prescription Medication Agreement”
if a controlled substance is to be continued for more than 30 days for treatment of pain. I understand that this agreement will be updated every 365 days or if there is a change to my treatment plan. I understand that attempting to reduce my pain is my responsibility and that the treatment of pain with controlled substances carries with it some additional responsibilities, of which my practitioner has made me fully aware. The purpose of this agreement is to help both
my practitioner and me comply with the Nevada Law.
All medications must be used
ONLY
as prescribed and directed. My practitioner and I have discussed my individual treatment plan, giving me a good understanding of goals.
My practitioner and I have discussed possible alternative treatments for my pain that do not include controlled substance(s) and it is our mutual agreement that continuation of a controlled substance(s) for more than 30 days may provide some benefit for the treatment of my pain.
I understand that changes in my treatment plan may include coming in for an office visit and that there are various reasons my practitioner might recommend changing, tapering, or discontinuing use of a controlled substance(s). Some of the reasons may include, but are not limited to, a reduction of pain symptoms, adverse side effects, any signs of misuse or abuse of medications, diversion, addiction, refusal to comply with diagnostic studies, attempts to obtain medications from other providers, or use of illicit drugs and/or other medications that may interact with any controlled substance(s) I am prescribed.
I will inform my practitioner of any side effects of my medication. I will notify my practitioner if any medications affect my ability to operate machinery or drive a vehicle. If I receive an increased dose in my medications, I will be expected to
NOT
drive or operate machinery for 7 days.
I reaffirm my consent to monitor my prescription drug use when my practitioner deems it appropriate or necessary, including but not limited to, urine drug testing (UDT), saliva drug testing, and blood testing. I will bring my medications to my practitioner’s office at any time requested, where the number of pills may be counted. (In some instances, urine/saliva screening costs may become the responsibility of the patient.)
I will not share my medication with any other person. I agree to keep my medications in a secure location away from children and family members. It is my responsibility to immediately report to my practitioner and the local police department if my medications are stolen. This also includes “misplacing” my medications. Replacement of these medications will require an office visit and will NOT be provided to me until NPSS has received a copy of the police report.
NO EXCEPTIONS
.
I will immediately disclose to my practitioner if I have consumed
ANY
alcoholic beverage(s), as well as used
ANY
marijuana products, including cannabinoids. I understand that I am not allowed to consume either of these while taking controlled substances for the treatment of my pain.
I am aware that medications
NOT
taken as directed may
“run out early”
and that my requests for “early refills,” as well as, any requests for changes to my medication will require an office visit. I understand, in some situations,
“early refills”
may
NOT
be authorized or covered by my pharmacy benefits. I further understand early medication refill requests will require a
“Medication Refill Exception Form”
to be completed during an office visit
PRIOR
to any consideration for a refill.
I have been informed that regular medication refill requests are accepted Monday-Thursday during office hours and there will be
NO
medication refills on Fridays without an office visit. Additionally, I understand that medication refills are
NOT
available on weekends.
The on-call provider is available for emergency purposes ONLY and they will NOT refill my prescriptions.
I realize my written prescriptions must be picked up
IN PERSON
at the time of the appointment, unless otherwise previously arranged and I.D. will be required.
I will utilize A
single
pharmacy during my treatment with Nevada Pain and Spine Specialists (NPSS) and will provide notification of any change to my practitioner immediately.
It is my responsibility to make sure that I have an appointment scheduled for refills 28-30 days in advance, as well as any follow up appointments needed.
I understand that Nevada State Law requires me to provide a listing of every state in which I have previously resided or had a prescription for a controlled substance. Listed are such States:
(Required)
I am in complete understanding that staff at NPSS expect to be treated with respect and courtesy. Any rudeness and/or abusive behavior by me or on my behalf, toward
ANY
staff will not be tolerated and may result in dismissal of care from NPSS.
I agree to NPSS policy, that, as a patient, if I need to cancel or reschedule one of my
office appointments, a 24-hours notification is required.
I may cancel or change appointment by calling the office at (775) 689-5410 Monday – Friday, 8:00 am – 5:00 pm. If a 24-hour notice is NOT given for cancelation I will receive a
“no show”
for my appointment and will be assessed a
$50.00 fee
. No further appointments will be scheduled until the $50.00 fee is paid. Additionally, if I acquire
3 or more “no show”
appointments I may be discharged from NPSS.
I have also been informed, if I need to cancel or reschedule one of
my procedures, a 48-hour notification is required.
I may cancel or change procedures by calling the office at (775) 689-5410, Monday – Friday, 8am – 5pm. If a
48-hour notice
is
NOT
given, I will receive a
“no show”
for my procedure and will be assessed a
$100.00
physician fee. No further appointments will be scheduled until the $100.00 is paid.
FOR WOMEN ONLY:
I have been informed and consent to notify my physician/practitioner if I become pregnant or am thinking about becoming pregnant. I understand the risk of taking any controlled substance(s) while pregnant. Some of these risks to the developing fetus include, but are not limited to, fetal dependency on a controlled substance, fetal abnormalities, or even fetal death.
I am aware
ALL
patients, both existing and new to our facility, whom are being prescribed a controlled substance must undergo an assessment test called
Medical Stability Quick Screen (MSQS)
. New patients will complete the multiple choice test every 30 days from the day prescribed a controlled substance and existing patients will complete a test every 90 days while on a controlled substance. I understand this testing is to determine my risk for abuse, dependency, and addiction using valid evidence-based test questions. I am also aware that this assessment test will facilitate in determining my diagnosis. I agree to cooperate for these assessment tests.
I comprehend and agree to
FULL
participation in
ALL
prescribed treatment recommendations. Additionally, a commitment to all these rules is expected and essential for my treatment and care as a patient. Deviation from this agreement may lead to dismissal or discharge as a patient of NPSS.
By signing below, I indicate that I have received and read this agreement. I understand this agreement and hereby abide by all points listed.
DOB
(Required)
MM slash DD slash YYYY
PATIENT PRINT:
(Required)
Date
(Required)
MM slash DD slash YYYY
PATIENT SIGNATURE:
(Required)
Nevada Written Informed Consent
Controlled Substance Therapy for Pain
*****Please Initial*****
Patient #:
(Required)
My practitioner is prescribing pain medications including controlled substances. I have discussed with my practitioner the important provisions of my treatment plan established in a clear and simple manner.
(Required)
My practitioner is prescribing pain medications including controlled substances. I have discussed with my practitioner the important provisions of my treatment plan established in a clear and simple manner.
Every pain medication, including controlled substances, have different benefits and risks in the treatment of my symptoms.
(Required)
Every pain medication, including controlled substances, have different benefits and risks in the treatment of my symptoms.
Before I am prescribed pain medications, we discussed non-opioid alternatives, those specific to treatment of my symptoms include:
(Required)
Before I am prescribed pain medications, we discussed non-opioid alternatives, those specific to treatment of my symptoms include:
Symptoms include:
(Required)
When taking these medications, I may experience certain reactions or side effects that could be dangerous including sleepiness or sedation, constipation, nausea, itching, allergic reactions, problems with thinking clearly, slower reaction times, slower breathing, as well as other symptoms.
(Required)
When taking these medications, I may experience certain reactions or side effects that could be dangerous including sleepiness or sedation, constipation, nausea, itching, allergic reactions, problems with thinking clearly, slower reaction times, slower breathing, as well as other symptoms.
I have discussed with my practitioner and I understand the potential risk and benefits of treatment using controlled substances, including a form of the controlled substance that is designed to deter abuse.
(Required)
I have discussed with my practitioner and I understand the potential risk and benefits of treatment using controlled substances, including a form of the controlled substance that is designed to deter abuse.
When taking these medications, it may not be safe to operate machinery, drive a vehicle or take care of other people. If I feel sedated, confused, or otherwise impaired by these medications, I should not attempt to do anything that may put others or myself at risk of injury.
(Required)
When taking these medications, it may not be safe to operate machinery, drive a vehicle or take care of other people. If I feel sedated, confused, or otherwise impaired by these medications, I should not attempt to do anything that may put others or myself at risk of injury.
When taking these medications regularly, I may become physically dependent on them meaning, my body will become accustomed to taking these medications every day. I will experience withdrawal sickness if I stop them or cut back on them too quickly. Withdrawal symptoms feel like having the flu and may include abdominal pain, nausea, vomiting, diarrhea, sweating, body aches, muscle cramps, runny nose, yawning excessively, anxiety, and/or sleep problems.
(Required)
When taking these medications regularly, I may become physically dependent on them meaning, my body will become accustomed to taking these medications every day. I will experience withdrawal sickness if I stop them or cut back on them too quickly. Withdrawal symptoms feel like having the flu and may include abdominal pain, nausea, vomiting, diarrhea, sweating, body aches, muscle cramps, runny nose, yawning excessively, anxiety, and/or sleep problems.
I may become addicted to these medications and require addiction treatment if I cannot control the usage of how I take my medications. If I use them inappropriately, I may have bad or dangerous things happen because of the medications. I have discussed with my practitioner the proper use of my controlled substance(s).
(Required)
I may become addicted to these medications and require addiction treatment if I cannot control the usage of how I take my medications. If I use them inappropriately, I may have bad or dangerous things happen because of the medications. I have discussed with my practitioner the proper use of my controlled substance(s).
Anyone can develop an addiction to pain medications, however, people who have had problems with mental illness or controlling drug/alcohol use in the past are at a higher risk for addiction. I have discussed with my practitioner my previous family history, as well as my own history regarding these types of addiction problems.
(Required)
Anyone can develop an addiction to pain medications, however, people who have had problems with mental illness or controlling drug/alcohol use in the past are at a higher risk for addiction. I have discussed with my practitioner my previous family history, as well as my own history regarding these types of addiction problems.
I have discussed with my practitioner the methods to safely store and legally dispose all controlled substances. I understand that prescriptions should always be stored in a secure place and out of reach of children/family members. To safely dispose of unused medications, I can return my medications in the bottle to my local pharmacy, a local police or sheriff station, or I may safely dispose of them by dissolving them in a Dettera Bag, which I can purchase at my pharmacy.
(Required)
I have discussed with my practitioner the methods to safely store and legally dispose all controlled substances. I understand that prescriptions should always be stored in a secure place and out of reach of children/family members. To safely dispose of unused medications, I can return my medications in the bottle to my local pharmacy, a local police or sheriff station, or I may safely dispose of them by dissolving them in a Dettera Bag, which I can purchase at my pharmacy.
I understand the proper procedure for medication refill requests and how my practitioner will handle my requests.
(Required)
I understand the proper procedure for medication refill requests and how my practitioner will handle my requests.
I understand that due to the risk of possible overdose, resulting from inappropriate use of my medication, the opioid overdose antidote naloxone (Narcan) is now available without a prescription. I may obtain Narcan from a pharmacist.
(Required)
I understand that due to the risk of possible overdose, resulting from inappropriate use of my medication, the opioid overdose antidote naloxone (Narcan) is now available without a prescription. I may obtain Narcan from a pharmacist.
FOR WOMEN: It is my responsibility to tell my practitioner immediately if I think I am pregnant or if I am thinking of becoming pregnant. I understand the risk to a fetus of chronic exposure to controlled substances during pregnancy including the risks of fetal dependency on the controlled substance, neonatal abstinence syndrome, or fetal death.
FOR WOMEN:
It is my responsibility to tell my practitioner immediately if I think I am pregnant or if I am thinking of becoming pregnant. I understand the risk to a fetus of chronic exposure to controlled substances during pregnancy including the risks of fetal dependency on the controlled substance, neonatal abstinence syndrome, or fetal death.
I have reviewed this form with my practitioner and have had the chance to ask any questions. I understand each of the statements written here and by signing, give my consent for treatment of my pain conditions with medications including those of a controlled substance.
Patient Print:
(Required)
Patient Signature:
(Required)
Date
(Required)
MM slash DD slash YYYY
If the patient is an un-emancipated minor, as the parent/guardian, I have discussed with the practitioner the risks that the minor will abuse or misuse the controlled substance.
Parent/Guardian Print:
(Required)
Parent/Guardian Signature:
(Required)
Date
(Required)
MM slash DD slash YYYY
