Controlled Substance Treatment Agreement

Use only when controlled medication is prescribed and after review of medication-specific requirements.

I agree to use controlled medication only as prescribed; not to share or sell medication; to use one primary prescriber/pharmacy when required by the treatment plan; to disclose other controlled substances; and to follow requested monitoring, follow-up, and safety requirements.

I understand that lost/stolen medication, early refill requests, unsafe use, diversion, or failure to follow the treatment plan may lead to reassessment or discontinuation of controlled medication, consistent with applicable law and clinical judgment