Absolute Medical Solutions, Inc.

 Controlled Substance Prescription Form

Controlled Substance medications (narcotics and benzodiazepines) can be very useful but have a high risk for misuse and abuse.  They are therefore closely controlled by local, state, and federal governments.  When used properly they are very effective medications.  However, if used in excess they may cause adverse effects.  To insure these medications are used properly, I agree to the following conditions.

  1. I am fully responsible for my controlled substance medications.  If my prescription medication is lost, misplaced, or stolen or if I use it up sooner than prescribed I understand that it will not be replaced.
  2. I will not request or accept any controlled substance medication from any other physician while under the care of the physician in which you are being referred to by AbsoluteMedicalSolutions.com unless I am a patient in the hospital or under emergency care.  Further, I understand that violating this is considered fraud and action can be taken against me.
  3. I understand that if I violate any of the above conditions my controlled substance prescription and/or treatment with AbsoluteMedicalSolutions.com physician, your care and treatment could end immediately.  If the violation involves obtaining controlled substances from another physician as described above I may also be reported to my primary physician, or local medical facility.
  4. I have been informed by my physician about narcotic and tranquilizer effects.  Including physiological effects of tolerance and dependence (withdrawal may occur if I stop the medication abruptly,) and addiction (abnormal physiological dependence).
  5. I understand that the main goal for treatment is to improve my ability to function at home and/or at work.

I have read, understand and agree to the “terms and conditions” as well as the “Contract for controlled substances.”  I attest that all information submitted is true and correct I am freely entering into this agreement with AbsoluteMedicalSolutions.com.

  

  Print Name: _________________________________

 
  Signature:___________________________________

 
  Date:_______________________________________

 

(THIS PAGE MUST BE PRINTED, SIGNED AND FAXED WITH YOUR RECORDS)