CONTROLLED SUBSTANCE USE CONTRACT
Date:

PATIENT NAME:
PHARMACY:

I will obtain my controlled substance prescription(s) only from Skyline Family Practice. I further understand that trying to obtain controlled substances from other physicians other than those physicians at Skyline Family Practice may be illegal and have legal consequences for me.
I will obtain my controlled substance prescriptions from only one pharmacy which is noted above.
I understand and will be informed of the operating hours of this pharmacy. I give consent to allow Skyline Family Practice to fax the pharmacist a copy of this contract and allow them to keep it in their possession.
I WILL NOT make changes in dosage or frequency of medication without prior discussion with the doctor.
I WILL NOT seek nor ask for early refills. I understand that no excuses such as the prescription medication being stolen, lost, or accidentally destroyed will be accepted. I understand that the prescription dosage and frequency is designed for my needs and that if I run out of medication early, there may be consequences such as withdrawal symptoms and increased pain or other symptoms.
I will not harass or repeatedly speak with the pharmacist about refills which may be early.
I will allow the pharmacist to contact Skyline Family Practice when a refill requires the approval of the physician. I WILL NOT contact the physician's office for this routine procedure but allow the pharmacist to reasonably contact Skyline Family Practice.
I WILL NOT call the physician after hours about my controlled substance prescription refills.
I consent to get any consultations or referrals that the doctor may recommend. These consultations can include specialty physicians, multidisciplinary consultations and affiliated medical specialists such as counselors, physical therapists and educators.
I will abstain from alcohol and illegal drug use.
I will obtain urine drug screens (or other tests) when asked.

I understand that if I do not follow the above contract (in whole or part), my controlled substance prescription(s) may be discontinued abruptly. Furthermore, such breach of behavior could possibly lead to criminal investigation and/or discharge from Skyline Family Practice as a patient. My signature below indicates that I fully understand this contract and have had any questions fully explained to me.

Patient Signature:	__________________________________________
Witness:	__________________________________________

OFFICE USE ONLY:	Original to chart, with copy to patient and pharmacy (via fax)
	Initials: ___________ Date: ___________