"Pain Treatment Agreement Template - Virginia Commonwealth University"

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Pain Treatment Agreement
I understand that I have a right to comprehensive pain management. I understand that this agreement aims to improve
the safety and efficacy of pain management. I understand that failure to follow any of these agreed statements might
result in Dr. __________________________ not providing ongoing care for me.
I, ______________________________________,agree to undergo pain management by Dr.______________________.
My diagnosis is______________________________________________________. I agree to the following statements:
I will not accept any narcotic prescriptions from another doctor.
I will be responsible for making sure that I do not run out of my medications on weekends and holidays, because abrupt
discontinuation of these medications will cause severe withdrawal syndrome.
I understand that I must keep my medications in a safe place.
I understand that Dr. _______________will not supply additional refills for the prescriptions of medications that I may lose.
If my medications are stolen, Dr. _______________________ will refill the prescription one time only if a copy of the
police report of the theft is submitted to the physician's office.
I will not give my prescriptions to anyone else.
I will only use one pharmacy.
I will keep my scheduled appointments with Dr. ______________unless I give notice of cancellation 24 hours in advance.
I agree to refrain from all mind/mood altering/illicit/addicting drugs including alcohol unless authorized by Dr.___________
My treatment plan may change based on outcome of therapy, especially if pain medications are ineffective. Such
medications will be discontinued. My treatment plan includes:
Medications ______________________________________________________
Physical therapy/exercise _______________________________________________
Relaxation techniques_______________________________________________
Psychological counseling _______________________
I understand that Dr. ___________________________ believes in the following "Pain Patient’s Bill of Rights."
You have the right to:
Have your pain prevented or controlled adequately.
Have your pain and medication history taken.
Have your pain questions answered.
Know what medication, treatment or anesthesia will be given.
Know the risks, benefits and side effects of treatment.
Know what alternative pain treatments may be available.
Ask for changes in treatments if your pain persists.
Receive compassionate and sympathetic care.
Receive pain medication on a timely basis.
Refuse treatment without prejudice from your physician.
Include your family in decision-making.
Termination Clauses
A. The doctor may terminate this agreement at any time if he/she has cause to believe that I am not complying with the
terms of this agreement, or to believe that I have made a misrepresentation or false statement concerning my pain or my
compliance with the terms of this agreement.
B. I understand that I may terminate this agreement at any time.
If the agreement is terminated, I will not receive prescribed controlled medications but can remain a patient of Dr.
_____________________ and would strongly consider treatment for chemical dependency if clinically indicated.
______________________________
______________
______________________________
______________
Patient Signature
Date
Prescriber Signature
Date
Adapted from WebMD Pain Management Guide. Pain Management: Your Pain Treatment Agreement. Available at
http://www.webmd.com/pain-
management/guide/pain-management-pain-treatment-agreement. Accessed June 3, 2010.
Pain Treatment Agreement
I understand that I have a right to comprehensive pain management. I understand that this agreement aims to improve
the safety and efficacy of pain management. I understand that failure to follow any of these agreed statements might
result in Dr. __________________________ not providing ongoing care for me.
I, ______________________________________,agree to undergo pain management by Dr.______________________.
My diagnosis is______________________________________________________. I agree to the following statements:
I will not accept any narcotic prescriptions from another doctor.
I will be responsible for making sure that I do not run out of my medications on weekends and holidays, because abrupt
discontinuation of these medications will cause severe withdrawal syndrome.
I understand that I must keep my medications in a safe place.
I understand that Dr. _______________will not supply additional refills for the prescriptions of medications that I may lose.
If my medications are stolen, Dr. _______________________ will refill the prescription one time only if a copy of the
police report of the theft is submitted to the physician's office.
I will not give my prescriptions to anyone else.
I will only use one pharmacy.
I will keep my scheduled appointments with Dr. ______________unless I give notice of cancellation 24 hours in advance.
I agree to refrain from all mind/mood altering/illicit/addicting drugs including alcohol unless authorized by Dr.___________
My treatment plan may change based on outcome of therapy, especially if pain medications are ineffective. Such
medications will be discontinued. My treatment plan includes:
Medications ______________________________________________________
Physical therapy/exercise _______________________________________________
Relaxation techniques_______________________________________________
Psychological counseling _______________________
I understand that Dr. ___________________________ believes in the following "Pain Patient’s Bill of Rights."
You have the right to:
Have your pain prevented or controlled adequately.
Have your pain and medication history taken.
Have your pain questions answered.
Know what medication, treatment or anesthesia will be given.
Know the risks, benefits and side effects of treatment.
Know what alternative pain treatments may be available.
Ask for changes in treatments if your pain persists.
Receive compassionate and sympathetic care.
Receive pain medication on a timely basis.
Refuse treatment without prejudice from your physician.
Include your family in decision-making.
Termination Clauses
A. The doctor may terminate this agreement at any time if he/she has cause to believe that I am not complying with the
terms of this agreement, or to believe that I have made a misrepresentation or false statement concerning my pain or my
compliance with the terms of this agreement.
B. I understand that I may terminate this agreement at any time.
If the agreement is terminated, I will not receive prescribed controlled medications but can remain a patient of Dr.
_____________________ and would strongly consider treatment for chemical dependency if clinically indicated.
______________________________
______________
______________________________
______________
Patient Signature
Date
Prescriber Signature
Date
Adapted from WebMD Pain Management Guide. Pain Management: Your Pain Treatment Agreement. Available at
http://www.webmd.com/pain-
management/guide/pain-management-pain-treatment-agreement. Accessed June 3, 2010.
How You Can Help Control Your Pain
Your provider will review and write down the different ways that you can help yourself live and function with pain.
Exercise
Mental Health
Your diagnosis:
Education about
diagnosis
Procedures for
Pain
website:
other Pain relievers
drugs
My Treatment goals:
1.
2.
3.
VCU Chronic Nonmalignant Pain Curriculum
© 2006 Virginia Commonwealth University
Do not redistribute. No derivative works are to be made.
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