Fill out and submit the form below with the correct information.
THE USE OF ANY CONTROLLED MEDICATION IS ONLY ONE PART OF TREATMENT FOR MY PSYCHIATRIC HEALTH.
THE GOALS FOR USING THIS MEDICINE ARE:
PROVIDER RESPONSIBILITIES
PATIENT RESPONSIBILITIES
PRESCRIPTIONS FROM OTHER PROVIDERS
If I get a pain medicine, sleep or anxiety medicine or a stimulant medicine from someone outside of primary care such as a dentist, psychiatrist or emergency room provider, I will tell my provider or nurse the next time I am in clinic. I will bring this medicine to Dr. Harriet Asamoah in the original bottle even if the bottle is empty.
REFILLS
PRIVACY
While I am taking this medicine, my provider may need to contact other providers or family members to get information about my care and use of this medicine.
STOPPING THE MEDICATION
If I do not follow this agreement, or if my provider decides that this medicine is hurting me more than helping me, this medicine will be stopped in a safe way.
I HAVE BEEN TOLD ABOUT THE POSSIBLE RISKS AND BENEFITS OF THIS MEDICINE