Agreement for Benzodiazepine Prescriptions
The use of benzodiazepines may cause addiction and is only one part of the treatment for anxiety/insomnia.

The goals of this/ these medicines are to:

1. Improve my ability to work and function at home
2. To help my anxiety/insomnia as much as possible without causing dangerous side effects.

I have been informed that:

1. If I drink alcohol or use street drugs, I may not be able to think clearly and I could become sleepy and risk personal injury
2. I may get addicted to this medication
3. If I or anyone in my family has a history of drug or alcohol problems, there is a higher risk of addiction
4. If I need to stop this medication, I must do it slowly or I may get very sick

I agree to the following:

1. I am responsible for my medication. I will not share, trade, or sell my medicine. I will not take anyone else’s medicine
2. I will not increase my medicine until I speak with my provider
3. My medicine may not be replaced if lost, stolen, or used up sooner than prescribed
4. I will keep all appointments set up by my doctor
5. I agree to give a blood or urine sample, if asked, for the purposes of a drug test
6. I will only use one pharmacy for this medication and my doctor may speak with the pharmacist.
7. I will not try to obtain this medication from any other providers

Prescriptions from other doctors:
If I see another doctor who prescribes me a controlled substance, I must bring the prescription bottle to my next appointment at Alliance Psychiatry, even if it is empty.

Termination of Agreement: If I break any of the rules or if my provider decides that this medicine is hurting me more than it is helping me, this medicine may be stopped by my provider in a safe way. I have talked about this agreement with my provider and I understand the rules above.
Consent *
Full Name *
Date of Birth *
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