Controlled Substance Medicine Managment Agreement Patient Name(Required) First Last Date of Birth(Required) Month Day Year Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Cell Phone(Required)Controlled Substance Medicine Management Agreement(Required)Controlled Substance Medicine Managment Agreement: • Get my controlled medicine only from Dr. Michael Schoenwalder, DO. • Take my controlled medicine as prescribed. • Keep all my pre-scheduled 3-6 month follow up appointments and tell my doctor/nurse practitioner about all my health problems, even those not related to my chronic issue. • Tell my doctor/nurse practitioner about ALL my other medicines. This includes prescriptions from other doctors as well as over the counter and herbal medicines I decide to take. • Tell my doctor/nurse practitioner if I go to an emergency room, urgent care, or another doctor to get more controlled medicine. • Tell my other doctors about all the medicine I take or have been prescribed by other doctors. • Allow my doctor/nurse practitioner to talk with other physicians and pharmacists regarding my medicine. • Allow doctor/nurse practitioner, or any other to test my blood and urine to confirm that I am taking only my prescribed controlled medicine as directed and nothing more. *** NOTE: The urine test done in office costs $30.00. ***This will be done at every appointment. • Keep my narcotic medicine safe to prevent anyone from stealing it or taking it accidently. • Be aware that there will be a $25 charge for each controlled prescription written or sent electronically to the pharmacy. • Use only one pharmacy for filling prescriptions for my prescribed controlled medicine. I have read and agree to the conditions listed in this section.I will not:(Required)I will not do the following: • Change how I take controlled medicine without first talking with my doctor/nurse practitioner. • Share, sell, or trade my medicine. • Use illegal drugs or abuse alcohol. • Take drugs prescribed for other people. I have read and agree to the conditions listed in this section.When I refill my controlled medication prescription I will:(Required)When I refill my controlled medication prescription I will: • Not ask for early refills (more medicine), even if I lose or misplace my medicine. • I will not ask or seek other providers to prescribe my controlled medicine for me. • Follow my doctor’s/nurse practitioner’s refill policy. I have read and agree to the conditions listed in this section.I acknowledge:(Required)I acknowledge the following: • Controlled medicine with narcotics can be addictive. This means that my body may need more and more medicine or that it can be hard to stop taking this medicine. • I may need other medication and tests to diagnose and treat my health problems. • For those on Pain medicines: ----Pain medicine treats my pain but not its causes. ----Pain medicine can cause side effects. It may cause me to be sleepy or slow my reflexes (how I respond or think). These side effects can make it unsafe to drive a car or use machines. I will refer to my prescription insert for a full list of potential side effects. • For those on ADD/ADHD medicines: Note: ADD/ADHD medicines can cause side effects. It may cause trouble sleeping, increase blood pressure, headaches, weight loss, and mood changes. - I will refer to my prescription insert for a full list of potential side effects. • My doctor or nurse practitioner will access the Prescription Drug Monitoring Database (PDMD), which tracks all controlled medicine prescribed to me by any physician. I have read and agree to the conditions listed in this section.My Agreement:(Required)My doctor/nurse practitioner and I talked about my controlled medicine. I have read this agreement, understand it and have had all my questions answered. I understand that I must follow this agreement. If not, my doctor or others at Michael Schoenwalder, DO LLC will not prescribe controlled medicine for me. They may also refuse to provide all my medical care if I do not follow this agreement. I have read and agree to the conditions listed in this section.Credit Card on File(Required)Credit Card on File: I authorize Michael Schoenwalder DO LLC DBA Schoenwalder Health & Wellness to charge my credit card account for the aforementioned fees. This card will automatically be charged when make a request for new prescription refill. Please note that once your credit card information is entered, it is encrypted and cannot be viewed or accessed by our organization. Our system is registered with PayPal and is a certified PCI compliant provider. Refusal to provide credit card information will not exempt you from receiving a charge for missed appointment fees. If you supply a credit card to us verbally, it will be assumed you have authorized the use of this card for any outstanding balances. I have read and agree the Credit Card on File statement.SIGNATURE(Required)By typing your full name below you are indicating your signature and that you accept all the terms and conditions forementioned in this form.
