As a participant in treatment for pain management, I freely and voluntarily agree to accept this treatment contract as follows:

1. I agree not to sell or give any of my medication to another person. I understand that it is illegal and could result in being discharged.

2. I agree that my prescription can only be given at my regular doctor visits. If I miss a visit/or cancel my appointment I cannot get my medication/prescription until the next doctor visit. (Unless a documented emergency occurs).

3. I understand that narcotic medications will NOT be called in. I understand the DR will NOT refill any narcotic medication without a visit. NO early refills permitted.

4. I agree NOT to get ANY other narcotic pain medicine from another doctor, unless an Emergency. I agree that ONLY the DR will prescribe my pain medicine. If narcotic pain medicine is prescribed in my name (after I sign this agreement) I could be discharged.

5. I agree that any rude, inappropriate, or threatening behavior to the doctor, his staff, or the pharmacy may result in being discharged.

6. I agree that the medication I receive is my responsibility. I agree to keep it in a safe, secure place. I agree that medication may not be replaced if lost or stolen.

7. I agree to take my medication as instructed and not to change (increase or decrease) the way I take my medication without first asking my doctor.

8. I agree NOT to take any benzodiazepam medications (Valium, Klonipin, Xanax, etc.) unless authorized/prescribed by the DR or under emergency conditions at a hospital.

9. I understand that medication alone is not sufficient treatment for my condition. Other treatments, including Physical Therapy or even possible intervention/injections, and/or surgery may be recommended as part of my treatment.

10. I agree not to take any other narcotics/*pain medicine, cocaine, or addictive/illegal substance(s). *Unless a hospital emergency, and then I will notify Traveling Doctor’s office with the hospital information.

11. I agree to provide random *urine samples. I understand that Michigan Guidelines for prescribing narcotic pain medicine include urine monitoring. If I refuse to provide urine for this purpose, the DR is NOT required to prescribe my pain medicine AND I may be discharged. *Dialysis patients agree to provide blood samples for monitoring.

12. I agree NOT TO TAKE SOMA; I understand the DR DOES NOT prescribe XANAX, due to its high abuse potential. The DR may prescribe a similar medication (Klonipin, Valium or other safer “cousins” to Xanax) if needed for short term severe anxiety. No cough syrup with Codeine will be prescribed, especially with pain medicine. 13. I agree if I use marijuana, Visiting Physicians of Detroit is not responsible for any interaction with my other medications.

14. I understand if I make suicidal statements, Visiting Physicians of Detroit is legally bound to call 911.

15. I understand that violations of the above may be grounds for termination of treatment.