South Georgia Internal Medicine

MEDICATION MANAGEMENT AGREEMENT Controlled narcotic medications are very useful but have a high potential for misuse and are, therefore, closely controlled by the state, local, and federal government. They are intended to relieve pain and improve function and/or ability to work. Because my physician is prescribing such medications to help manage my pain, I agree to the following conditions: I understand that the main treatment goal is to improve my ability to function and/or work and/or to reduce my pain. In consideration of that goal and the fact that I am being given potent medicine to help me reach that goal, I agree to follow my physician's directions throughout my treatment. I understand that the long-term advantages and disadvantages of chronic opioid use have yet to be scientifically determined and that my treatment may change throughout my time as a patient. I understand, accept, and agree that there may be unknown risks associated with the longer-term use of controlled substances and that my physician will advise me as knowledge and training advances occur and will make appropriate treatment changes as needed. IT IS THE PATIENT'S RESPONSIBILITY TO KNOW THEIR DETERMINED MEDICATION DOSAGES AS DISCUSSED AND/OR WRITTEN BY THE PHYSICIAN OR STAFF. IGNORANCE OF DOSING REGIME IS NOT AN EXCUSE FOR TAKING MORE OF THE PRESCRIPTION OR VIOLATING THE PRESCRIPTION IN ANYWAY. FAILURE OF TAKING THE PRESCRIPTION AS INSTRUCTED WILL CAUSE DISCHARGE FROM THIS FACILITY. NO EXCEPTIONS!!! Follow-up appointments must be kept. I will not accept or request pain medications from another physician while under the treatment of this facility. Besides being illegal to do so, it may endanger my health. No foul language or abuse of the office staff will be tolerated, to do so will cause discharge from this facility. REFILL POLICY: LOST, STOLEN, OR MISPLACED MEDICATION WILL NOT BE REFILLED EARLY. The dosage will only be increased or decreased by my physician. No refills will be made after 3:30pm daily nor before holidays or on weekends. NO REFILLS WILL BE GIVEN EARLY (before it is due). NO EXCEPTIONS!!! I AM RESPONSIBLE FOR MY MEDICATION. IF THE WRITTEN PRESCRIPTION OR MEDICATION IS LOST, MISPLCED, STOLEN, OR IF I USE MORE THAN PRESCRIBED, I UNDERSTAND AND AGREE THAT IT WILL NOT BE RENEWED EARLY. By signing this agreement, I have read and agreed to, and will abide by, the rules stated above.

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