Drug Abuse Sample Patient Agreement Forms (February 2018)

This resource includes two sample patient agreement forms that can be used with patients who are beginning long-term treatment withopioid analgesics or other controlled substances. These documents contain statements to help ensure patients understand their role and responsibilities regarding their treatment (e.g., how to obtain refills, conditions of medication use), the conditions under which their treatment may be terminated, and the responsibilities of the health care provider. These documents can help facilitate communication between patients and healthcare providers and resolve any questions or concerns before initiation of long-term treatment with a controlled substance.