PRESCRIPTION MEDS & CONTROLLED SUBSTANCE POLICY

Downloadable Version

Prescription Medication & Controlled Substance Policy

The office of Drs. Seaver and Pittman has developed this mutual agreement to pertain to the treatment of my medical conditions. I understand that the goal of treatment is to improve my functional ability, and in doing so, that sometimes requires narcotics and/or sedatives. These medications sometimes lead to abuse and dependency, though if used correctly, can be very effective. By checking and signing this document in the appropriate areas below, I understand my responsibility and agree to uphold this agreement.
I agree to obtain my prescriptions related to my medical/dental conditions only from this office. I understand that if another physician gives me a prescription for the same medication prescribed by this office, that I will notify that physician, as well as our office.
I will not ask for my medications to be dispensed or refilled early and I will allow 72 hours for these medications to be refilled if necessary. Request for refills are to be made during business hours only!!! No emergency phone calls for refills or changes in medications will be taken by our answering service!!! I understand and will only make my request during business hours and will only use one pharmacy for my prescriptions!
I will not share or trade prescriptions with anyone.
I will bring unused medication into our office for disposal in the event that a different strength of drug or alternate drug needs to be prescribed. No additional prescriptions will be given with unused medications not returned.
I am responsible for all medications. If they become lost, stolen, misplaced or if they disappear for any reason, I will not ask for refills early or new prescriptions to replace them.
I understand that my doctors will cooperate with any and all authorities, as these medications are monitored by governmental agencies.
I understand that while taking narcotics and/or sedatives that my ability to drive, operate machinery or make important decisions will be altered and I release my physician/ dentist of any liabilities stemming from my impairment. I will follow my doctors’ instructions on how to use my medications and will adhere to their instructions.
I understand that governmental agencies notify my doctor/dentist of over usage or potential for abuse and if notified of unusual prescription history, my physician/dentist will consult with each other prior to any further prescriptions being written. My doctors/dentist has the right to refuse certain medications if abuse potential is at risk or suspected.
I understand any altering of original prescriptions will result in immediate dismissal from our practice and notification of authorities. I also understand that failure to keep appointments, except in cases of emergency, may also result in dismissal.
SIGNATURE
Name*
Date*
Month
Day
Year

Mountain Empire Dental

Blountville Dental Assoc.

PRESCRIPTION MEDS & CONTROLLED SUBSTANCE POLICY

Prescription Medication & Controlled Substance Policy

SIGNATURE