Agreement for Psychostimulant Prescriptions
1. I agree that providers of Alliance Psychiatry LLC and Alliance Psychiatry Partners LLC will be the only providers prescribing psychostimulants. 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 provider. I understand that expected prescription refill dates will be used to promote optimal use of this medication.
3. My physician may require random urine drug testing as a matter of routine monitoring.
4. I will attend all reasonable appointments, treatments and consultations as requested by my physician.
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 understand that long term use of this medication and/or using doses above the recommended FDA dose ranges may cause dependence. If there is a history of addiction in my family, there is a higher risk of addiction for me.
7. I agree to be responsible for the secure storage of my medication at all times. I understand the importance of not informing others about my stimulant therapy. I agree not to give or sell my prescribed medication to any other person. I acknowledge that my provider is not obligated to replace any medication shortfall.
8. I consent to open communication between my provider and any other health care professionals involved in my treatment with stimulants, such as pharmacists, other providers, emergency depts, etc.
9. I understand that if I break this agreement, my provider reserves the right to stop prescribing stimulant medications for me.
I agree to the terms listed above.
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