I understand that I am receiving opioid medication from Dr. to treat my pain condition. I agree to the following:
- I will not seek opioid medications from another physician. Only Dr. will prescribe opioids for me.
- I will not take opioid medications in larger amounts or more frequently than is prescribed by Dr. .
- I will not give or sell my medication to anyone else, including family members; nor will I accept any opioid medication from anyone else.
- I will not use over-the-counter opioid medications such as 222’s and Tylenol® No. 1.
- I understand that if my prescription runs out early for any reason (for example, if I lose the medication, or take more than prescribed), Dr. will not prescribe extra medications for me; I will have to wait until the next prescription is due.
- I will fill my prescriptions at one pharmacy of my choice; pharmacy name: ______________________________________________________________
- I will store my medication in a secured location.
I understand that if I break these conditions, Dr. may choose to cease writing opioid prescriptions for me.