Send An Email

contact@ewingmentalhealthllc.com

Ewing Mental Health LLC

Controlled Substance Form

Fill out and submit the form below with the correct information.

CONTROLLED SUBSTANCE PATIENT‐PROVIDER AGREEMENT

THE USE OF ANY CONTROLLED MEDICATION IS ONLY ONE PART OF TREATMENT FOR MY PSYCHIATRIC HEALTH.

THE GOALS FOR USING THIS MEDICINE ARE:

  • To improve my ability to work or function at home.
  • To help my problem as much as possible.

PROVIDER RESPONSIBILITIES

  • To make sure this medicine is helping and not hurting you.
  • To NOT continue medicines prescribed by others unless they are safe and are the best treatment for your problem.
  • To routinely check the state Prescription Monitoring Program, to see the medicines that you are getting from me and others.
  • To work with other specialists to make sure you are getting the best treatment for your problem.

PATIENT RESPONSIBILITIES

  • I will follow the treatment plan including keeping all appointments set up by my provider. For example these may include primary care, physical therapy, mental health, addiction treatment, and pain management.
  • I am responsible for my medicines. I will not share, sell or trade my medicine.
  • I will keep my medicine in a safe place where no one else will be able to take them. They could be very dangerous to others, especially children.
  • I will not take anyone else's medicine.
  • I will not take extra medicine.
  • I will dispose of the medicine properly.
  • I understand that my medicine will probably not be replaced if it is lost, stolen, damaged or used-up sooner than prescribed.
  • I will bring the original pill bottles with all unused pills of this medicine to each clinic visit for pill counts. This includes visits with nurses or my provider.
  • I will come in for a pill count and urine drug test anytime I am asked to do so, even if I don't have a clinic appointment on that day.
  • I agree to give a urine sample for drug tests on the day it is requested whenever I am asked.
  • I will not use any street or illegal drugs. I will not use any medications that have not been prescribed for me.
  • I will not drink alcohol while taking this medicine unless my provider says it is safe to do so.
  • I understand that use of this medicine is a test or trial. My provider will continue this medicine only if the medicine is helping and not hurting me.
  • I will treat all people working in the clinic with respect.

PRESCRIPTIONS FROM OTHER PROVIDERS

If I get a pain medicine, sleep or anxiety medicine or a stimulant medicine from someone outside of primary care such as a dentist, psychiatrist or emergency room provider, I will tell my provider or nurse the next time I am in clinic. I will bring this medicine to Dr. Harriet Asamoah in the original bottle even if the bottle is empty.

REFILLS

  • Refills will be available during regular office hours.
  • No refills for this medicine on nights and holidays.
  • No early or emergency refills may be made.
  • I will pick up my refill prescription myself whenever possible. At rare times I will notify the clinic before the prescription is due, that a family member or friend will pick up the prescription for me.

PRIVACY

While I am taking this medicine, my provider may need to contact other providers or family members to get information about my care and use of this medicine.

STOPPING THE MEDICATION

If I do not follow this agreement, or if my provider decides that this medicine is hurting me more than helping me, this medicine will be stopped in a safe way.

I HAVE BEEN TOLD ABOUT THE POSSIBLE RISKS AND BENEFITS OF THIS MEDICINE

  • The medicine may help my problem but may cause other problems like addiction, overdose and death.
  • When I start this medicine, when my dose is increased or if I drink alcohol or use street drugs, I may not be able to think clearly. I could become sleepy and have an accident.
  • I may get addicted to this medicine. This could cause me to get into trouble and have problems at home or work.
  • If I or anyone in my family has a history of drug or alcohol problems, I will have a higher chance of addiction to this medicine.
Patient's Name(Required)