1. No pain medication will be prescibed to a new patient on their first visit. __________
2. Pain medication will ONLY be prescribed to patients who are deemed surgical candidates. Any patient outside of this category must see their primary care physician for management of any pain medications. __________
3. Pain medication will only be prescribed to surgical patients throughout their post-operative period. We are not a pain management facility and do not mange medication long term. __________
4. Medications must last a specific number of days and no medications will be called in prior to that date. __________
5. We will NOT refill prescriptions which have been misplaced. Please be responsible for keeping up with your medications. __________
6. Stolen medications will not be replaced without a valid police report. We will do this only ONE time. __________
7. If you are taking prescription narcotic/controlled substances, muscle relaxers, or tranquilizers which the manufacturer of the drug recommends not operating heavy machinery (which includes a motor vehicle), we cannot recommend that you act against their recommendations and will assume NO liability should you choose to do so. __________
8. Narcotics will NOT be phoned in. A new prescription must be picked up or mailed to you. __________
9. Refills must be obtained by calling 5 to 7 business days prior to the end of your prescription. This request must be made during our office hours (Mon-Fri 8am-5pm). Please do not show up unexpectedly to our office and request a medication refill. If you do so, we will be unable to process your request. You must obtain verification from our office staff that your prescription is ready to be picked up before coming to do so. __________
10. Patients may be terminated from the practice with 30 days notice, for noncompliance in the taking of their medications. __________
11. Altering or forging a prescription is grounds for immediate termination from the practice. This is a felony and will be reported. __________
12. Random drug screens will be performed on patients who are prescribed narcotics. If requested while in the office, the drug screen must be done immediately. If you are called at home to get a urine drug screen, this must be done within 24 hours. Failure to do so will result in termination from our practice. There will be NO exceptions to this policy. __________
13. We require that all medications be filled through one pharmacy only. Please provide us with the pharmacy that you wish to use for your medication refills in the space below. If at any point you wish to change your pharmacy, you must notify our office before doing so. __________
    Pharmacy Name: __________________________________________________
    Pharmacy Phone Number: ___________________________________________
14. If you are referred to pain management and are released/fired by your pain management physician, it is your pain management physician's obligation to make sure that you follow through with another pain management specialist or alternatively your primary care physician. We WILL NOT resume writing your medication. Please do not call our office requesting the same. It will be your sole responsibility. __________

This policy helps to assure that these potentially addictive medications are properly used, administered, and monitored. We appreciate your cooperation.

I have read and understand the above policy. By signing below, I agree to abide by this policy.

PATIENT SIGNATURE: _____________________________________________ DATE: ______________________

PATIENT NAME (Printed): __________________________________________________