CONTRACT FOR CONTROLLED SUBSTANCES

Controlled substance medication (narcotics-opiods, tranquilizers, barbiturates, i.e. any drug which induces sleep or stupor) can be very useful but have high potential for misuse and abuse and are, therefore, closely controlled by government agencies. Used properly, some of them can be very effective pain medication. If used excessively, however, they can cause adverse effects, such as impaired judgment, vomiting, constipation, lethargy, organ damage, or even death. To ensure these medications are used properly, I agree to the following conditions.

1. I am RESPONSIBLE for my controlled substance medication. IF THE PRESCRIPTION OR MEDICATION IS LOST, STOLEN OR MISPLACED OR IF I USE IT UP SOONER THAN PRESCRIBED, I UNDERSTAND THAT IT WILL NOT BE REPLACED.

2. I will not request or accept narcotic medications from any other physician or individual while I am receiving such medications from my doctor at Orthopaedic Specialists (except if I am in the hospital). Besides being illegal to do so (NRS 453.39 1), it may endager my health.
   
   
3. I understand that there will be a 24 to 48 hour turnaround time for non-narcotic medication refills; therefore, I will not wait until my medication is gone to request more medication. Controlled substances may be obtained only during a scheduled office visit. Refills will not be made at night, on holidays or on weekends.

4. I understand that if I violate ANY of the above conditions my controlled substance medication may be discontinued immediately. I am aware of “narcotic effects”, including physiological effects of tolerance (need for more medication to achieve the same pain relief) and dependence (withdrawal may occur if I stop my medications abruptly) and the effects of addiction (psychological dependence), which is less common in patients with true pain. I also understand that narcotics can adversely affect my judgment in making business decisions and in operating equipment, such as an automobile. I must use special care while involved in activities requiring clear thought and concentration.
   
   
   Signature of Patient / Guardian: _________________________________                   Date: _______________________________
   
   Witness Signature_________________________________                                         Date: _______________________________