Stimulant Use Agreement - insytepsychiatric.com

Stimulant Use Agreement

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Patient Agreement for Psychostimulant Therapy
Today's Date

Month Day Year
1. I blanks agree that Dr. blank will be the only physician prescribing (also known as STIMULANT), a medication for managing ADHD and that I will obtain all of my prescriptions for this medication at one pharmacy. The exception would be an emergency situation or in the unlikely event that I run out of medication. Should such occasions occur, I will inform my physician as soon as possible.
2. I understand the importance of taking the medication at the dose and frequency prescribed by my physician. I agree not to increase the dose of the medication without first discussing it with my physician. I understand that expected prescription refill dates will be used to promote optimal use of this medication.
3. My physician may require random urine testing as a matter of routine monitoring.
4. I will attend all appointments, treatments and consultations as requested by my physician. Iwill pursue other ADHD consultations/management strategies as necessary.
5. I understand that I should check with my physician or pharmacist before taking other medications including over-the-counter and herbal products.
6. I agree to be responsible for the secure storage of my medication at all times. I understand theimportance of not informing others about my stimulant therapy. I agree not to give or sell myprescribed medication to any other person. I acknowledge that my physician is not obligated toreplace any medication shortfall.
7. I consent to open communication between my doctor and any other healthcare professionals involved in my ADHD management, such as pharmacists, other doctors, emergency departments,etc.
8. I understand that if I break this agreement, my physician reserves the right to stop prescribing stimulant medications for me.
9. I understand that I will be required to meet with a Therapist from Insyte Psychiatric weekly.
Patient Name
Prescriber Name
Patient Signature

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Prescriber Signature

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Drug Used
Should be Empty: