INFORMED CONSENT and AGREEMENT FOR TREATMENT
ARTHRITIS CENTER of CT
revised July, 2007

1) Pain relieving medications, muscle relaxants, anti-anxiety or anti-depressant agents, and some sleep medications can lead to dependence, abuse, or addiction. These types of medications will only be obtained from the Arthritis Center while you are under our care, unless arrangements have been made with other practitioners.

2) These medications will be obtained only from the pharmacy noted below:

Pharmacy:

Address:

3) The medication you receive from us may be dangerous when combined with alcohol or any other potentially sedating or addicting substances. If you are using these substances it is your responsibility to discuss this with us. Undisclosed use of illegal substances or of potentially addicting substances (including methadone) may lead to your discharge from this office.

4) It is your responsibility to disclose any past or current history of drug problems or counseling.

5) Prescriptions for these types of medications will only be given in person. They can not be given over the telephone, or to a friend or family member without written permission from you, except in true emergencies or unexpected office closure due to weather.

6) You are responsible for your medication. Medications should not be left where they can be taken by minors or stolen by visitors. They should not be left in a locked car. Medications delivered should be handed directly to you. Medications that are stolen or lost even by accident (dropped in sink, eaten by the dog, left in the washing machine) will not be replaced. Prescription of these medications carries certain legal responsibilities,. Therefore patients must also demonstrate responsibility in the care and use of their prescriptions.

7) Abuse behaviors such as obtaining medications from friends, relatives, or other doctors, illicit purchase, hoarding, or unauthorized dosage increase, is unacceptable, and will be viewed as evidence of irresponsibility, result in the discontinuation of these medications or discharge from the practice.

8) You agree not to sell or give your medications to anyone else, including family members.

9) You agree that the staff of the Arthritis Center has permission to share your medical and medication history with any other medical or pharmacy providers involved in your care, or with law enforcement agencies.

10) You agree to have your urine screened for drugs from time to time on a random basis. Non-compliance may result in discharge from the practice.

11) Do not become pregnant while on these drugs, or your baby may be born drug-dependent. It is your responsibility to discuss pregnancy with us in advance, and to take appropriate precautions.

12) Medication should be taken on a schedule that is agreed upon between us. This will minimize the risk of abuse and provide you with greater control of your medication use. In addition, during the course of treatment we will periodically attempt to eliminate your dependence on these agents, if appropriate.

13) You understand that if you use up your medication ahead of schedule, extra medication will not be given, except in the case of an actual medical emergency.

14) The Arthritis Center staff reserves the right to insist, in selected cases, that a third party take responsibility for procurement and dispensing of medications.

15) "If my medication makes me drowsy, or when starting a new medication, I must refrain from operating machinery or motor vehicles or taking care of children. If I unintentionally hurt myself or anyone else, I accept full responsibility and absolve the Arthritis Center and its staff of responsibility."

Patient: _____________________________________ Date: _________________

Medical Staff: ______________________________ Date: _________________