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Psychotropic Medications: Patient Agreement
Name
First
Last
Date of Birth
Month
Day
Year
Provider
--Please Select--
April Nandigam
Grace Nicklas-Morris
Joe Harris
Kadie York
Lisa Bates
Madison Stonewall
Mikaela Coleman
Morgan Kingrey
Sarah Beatty
Theresa Moore
This form will go directly to the person you select.
Today's Date
Month
Day
Year
Examples of Controlled Substances:
Benzodiazepines:
Alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), clobazam (Onfi), clorazepate (Tranxene), diazepam (Valium), estazolam (ProSom), flurazepam (Dalmane), lorazepam (Ativan), midazolam (Versed), oxazepam (Serax), quazepam (Doral), temazepam (Restoril).
Stimulants:
Methylphenidate (Ritalin, Concerta, Metadate, Methylin, Daytrana), dexmethylphenidate (Focalin), amphetamine-salts (Adderall, Evekeo), dextroamphetamine (Dexedrine, Vyvanse, Zenzedi).
Sleep Medicines:
Eszopiclone (Lunesta), zaleplon (Sonata), zolpidem (Ambien, Edluar, Intermezzo), suvorexant (Belsomra), lumborexant.
Opioids*:
Buprenorphine, codeine, hydrocodone, hydromorphone, fentanyl, meperidine, morphine, tramadol, oxycodone, oxycontin.
Other:
Modafinil (Provigil, Nuvigil), pregabalin (Lyrica), dronabinol (Marinol)*, gamma hydroxybutyric acid (Xyrem)*, barbiturates*.
*Not prescribed at the Mood Treatment Center
I understand and voluntarily agree that (initial each statement after reviewing):
(Required)
I will keep the medicine safe, secure, and out of the reach of children.
I will take my medication as instructed and not change the way I take it on my own.
I will not sell this medicine or share it with others.
I understand that I have been given prescription(s) for enough medicationuntil my next office visit (including necessary refills). If I need additional medicationdue to a missed appointment, I will need to call for an urgent appointment.
I will make sure I have an appointment for refills. If I am having trouble makingan appointment, I will tell a member of the treatment team immediately.
I will keep (and be on time for) all my scheduled appointments with the provider and other members of the treatment team.
I will always treat the staff at the office respectfully.
I will sign a release form to allow the provider to speak to other providers that I see.
I will tell the provider all other medicines that I take and let them know right away if I have a prescription for a new medicine.
I will not accept or obtain prescriptions for benzodiazepines (Klonopin, Xanax, Ativan, Valium, etc.) or stimulants (Ritalin, Adderall, etc.) fromother providers. If I am prescribed pain medication that contains opioids, I will promptly notify my provider of the prescription.
I will promptly notify my provider if I take medications that are not prescribed for me including amphetamines, cocaine, opioids, fentanyl, benzodiazepines, and cannabis products.
If I am capable of becoming pregnant - I recognize there may be serious potential risks of taking psychotropic medications on a fetus and growingbaby. I will discuss my plans to get pregnant with my provider and notify my provider promptly if I become pregnant.
I understand that I may lose my privilege to be treated in this office if I break any part of this agreement.
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(336) 722-7266
