ADULT ADHD SELF-REPORT SCALE - Clearwater Aesthetics

Effective 01/01/2022

Patient Name(Required)

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Please note this policy supersedes and replaces any previous controlled substance policy or is in addition to; the decision to prescribe controlled substances is entirely up to each independent provider. This is an arrangement between(Required)

and your medical provider(Required)

Please read carefully, as this is a legal document. At the time of your visit:

Each patient’s history will be reviewed by the provider. When it is identified that a patient is already on a controlled substance or asks for a controlled substance during the visit; the EFORCSE, Florida Prescription Drug Monitoring Program/tracking report will be pulled from the database and individually reviewed.
A new patient with a history of a controlled substance will have their urine tested on the first appointment for a baseline drug screening. This will be reviewed with the patient during their appointment.
If it is decided by the provider to issue any Rx for a controlled substance on the next appointment, the patient will either be required to take a saliva drug swab or a urine sample for analysis of compliance.
State law now requires that a patient's urine is tested a minimum of eight times annually. This means that the testing can be done at any follow up appointment, at the time of refill, or randomly,as deemed appropriate by the provider.
During each follow up appointment, the patient on Schedule II or III medications must bring the bottle and any medication remaining to the visit.
Random pill counts and urine drug screening may be done to monitor compliance; patients will have four hours from the time of notification to arrive at the office with their medication.
We are not a chronic pain management center, and as such, we will not dispense large amounts of pain medications. If you have chronic pain, you will be referred to pain management.
Patients will read and comply with non opioid pain management options included in OPIOID REMS.
Refusal to complete any part of this policy can result in the cessation of the medications and/or termination from the practice.

The following was reviewed with the patient and agreed upon:

Patients will take this medication only as prescribed and will not change the amount or frequency without authorization from the prescribing provider.(Required)

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We will not provide early refills or receive replacement of lost or stolen medication.(Required)

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Patients are required to obtain the prescription only at a pre-agreed pharmacy location.(Required)

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Patients may be randomly asked to bring in medication to the office for pill counting, they will have four hours to respond.(Required)

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Patients are required to submit random urine or blood tests to assess compliance to treatment.(Required)

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Patient-Provider relationship is terminated if regularly scheduled appointments are not kept or the prescribed treatment plan is not followed.(Required)

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Patients are required to confirm by signature that they have not given any false health facts and are not seeking treatment under false pretense.(Required)

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Florida prescription database will be checked prior to each refill of a controlled substance.(Required)

Please Initial

Patient Signature(Required)

Provider Signature(Required)

Witness Signature(Required)

Effective 01/01/2022

Clearwater

International Plaza Tampa

Miami

Orlando

Effective 01/01/2022

Clearwater

International Plaza Tampa

Miami

Orlando

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