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Controlled Substance Patient Prescription Agreement Mobile App

The main treatment goal for the management of chronic pain is to improve a patient’s ability to function and/or work. The goal is to improve their functional ability for as long as possible and to relieve suffering. This usually involves many different kinds of treatments and medications that work together to decrease pain. The Controlled Substance Patient Prescription Agreement mobile app allows health care professionals to document controlled substance medications agreements and inform patients of risks associated with misuse using a smartphone or tablet. Access your data at the office, in the field or at home with the GoCanvas Cloud.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Controlled Substance Patient Prescription Agreement Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

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    Name

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    Hospital

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    Physicians

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    MR #

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    (Or Patient Label Here)

  • Ico statictext

    The main treatment goal for the management of chronic pain is to improve my ability to function a...

  • Ico statictext

    I understand that controlled substance medications (i.

  • Ico statictext

    I agree to help myself by following my providers’ recommendation regarding exercise/activity, sl...

  • Ico statictext

    I understand that my pain will be assessed and monitored on a regular basis to see how the treat...

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    3. I agree to follow the recommendations of Dr/NP

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    and his/her staff to manage my pain and other contributing health conditions.

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    4. I will not seek treatment from an emergency department or another provider for my chronic pain...

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    or his/her staff.

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    prior to going to the emergency department due to the nature of the emergency, I will inform Dr/NP

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    that I have gone to the emergency department as soon as reasonably possible afterwards.

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    I am responsible for my controlled substance medications.

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    6. I will not request or accept controlled substance medication from any other physician or indiv...

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    The only exception is while I am admitted to a hospital.

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    before I am discharged if I have concerns that my previously prescribed medications may not provi...

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    7. Refills for controlled substance medications:

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    Will be made only during regular office hours according to the policy of my provider’s office.

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    Will not be made at night, or on holidays, or on weekends.

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    Some of my prescription medications may cause drowsiness.

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    I will use only one pharmacy for all of my controlled substance medications and give my provider...

  • Ico textbox

    and the telephone number is

  • Ico textbox

    10. I will keep all scheduled appointments with Dr/NP

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    or his/her associates or reschedule at least 24 hours in advance of the appointment according to ...

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    I will bring in the original containers from the pharmacy for all medications prescribed each ti...

  • ...and More!

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