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Controlled Substance Medication Agreement
The use of this ,, (print names of medication(s) may cause addiction and is only one part of the treatment for my mental health condition.

The goals of this medicine are:

                ✓ To improve my ability to function at work and my ability to function at home.

                ✓ To improve my condition as much as possible without causing dangerous side effects.

I agree to the following:

                - I will take the medication only as prescribed

                - I will not share the medication with any other person

                - I agree to inform mu provider of the following,

                        •     Of any other controlled substances, I’ve consumed either those prescribed or otherwise

                        •     Whether or not I consume alcohol or other cannabinoid compound while using prescribed controlled substances.

                        •     Whether or not I have been treated for side effects or complications related to the use of controlled substances related to the use of controlled substance, including if I have experienced an overdose.

                        •     Any other state I have previously resided or had prescription for a controlled substance filled.

                - I agree to random pill counts of the prescribed medication in my possession

                - I agree to testing and monitoring of drug use when deemed medically necessary by my provider.

I understand that my provider may change or discontinue this controlled substance treatment if failed to abide to the follow agreement listed above.

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I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.

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