Eaux Claires Med, PLLC Agreement for Attention Deficit Disorder Prescriptions

Patient Name:

The goals of treatment with this medication are:

To improve my ability to function at work and home.

To help my ADD as much as possible without causing dangerous side effects.

·      I have been informed that this is a controlled medication and that I must take this medication only as prescribed. I must not use this medication in conjunction with any street drugs.

·      I am responsible for my medication. I will not share, sell, or trade my medication. I will not take anyone else’s medication.

·      I will not increase my medication without speaking with my doctor.

·      Lost, stolen, or destroyed medication will not be replaced.

·      I will keep follow up appointments every 3 months.

·      Refills outside of visits will be made within 48 hours time on weekdays.

·      Refills may be picked up no more than 3 days early.

·      I will pick up my medication at one pharmacy unless there is an extenuating circumstance.

·      I understand that my doctor will check the NC PMP Aware database to monitor my prescription fills.

·      I will not obtain ADD medication prescriptions from any other healthcare providers.

·      If I violate this agreement, I understand that this doctor-patient relationship may be terminated.

The name of my pharmacy is ______________________________________

Patient signature________________________________

Date_________