This is your full Controlled Substance Agreement & Treatment Plan. Please read it carefully and ask your provider about anything you do not understand before you sign. You can also download the printable PDF version to review or bring to your appointment.
Purpose of This Agreement
You have been prescribed a controlled substance as part of your treatment plan at Nervana Medical. Controlled substances (medications classified by the DEA as Schedule II–V, such as certain sedatives, stimulants, ketamine, and other regulated medications) can be very helpful when used correctly, but they also carry risks including dependence, misuse, serious side effects, and with some medications; overdose.
This agreement explains how these medications will be prescribed and monitored. Its purpose is to protect your health and safety, to make sure you clearly understand the treatment, and to keep both you and your provider in compliance with the law. Please read every section carefully and ask questions about anything you do not understand before you sign.
Our Approach to Chronic Pain
At Nervana Medical, we do not prescribe or manage chronic pain with opioid medications. Instead, we focus on evidence-based, multimodal treatment options such as medical cannabis, ketamine infusions, and other non-opioid therapies when appropriate.
Our goal is not only to improve pain but also to identify and address potential underlying causes. This may include evaluating for hormone imbalances, vitamin or nutrient deficiencies, inflammatory conditions, or other medical issues that may be contributing to your symptoms. When indicated, we may recommend additional diagnostic testing or referrals to help guide treatment.
If your pain remains inadequately controlled despite these therapies, we will refer you to an appropriate pain management specialist for further evaluation and treatment. Our philosophy is to treat the whole person whenever possible while collaborating with specialists when more advanced pain management is needed.
One Provider, One Pharmacy
- I agree to receive controlled-substance prescriptions from only one provider/practice (Nervana Medical or the provider named above), unless there is a documented emergency.
- I agree to fill these prescriptions at only one pharmacy. If I need to change pharmacies, I will inform my provider.
- I will tell my provider about ALL other medications I take, including any controlled substances prescribed by another clinician (for example, in an emergency room or by a specialist).
Safe Use of the Medication
- I will take the medication only as prescribed; the correct dose, at the correct times, by the route directed.
- I will not increase, decrease, or stop the medication, or change how I take it, without first talking to my provider.
- I understand this medication may impair my judgment, coordination, and reaction time. I will not drive, operate machinery, or perform any activity that could be dangerous to myself or others while impaired, and I will follow any specific driving/activity restrictions given to me for this medication.
- I will not drink alcohol or use recreational/illicit drugs while taking this medication, and I will not combine it with other sedating or controlled substances unless my provider has approved it.
Storage, Supply & Sharing
- I will store this medication securely, out of reach of children, pets, other household members, and visitors, and I will keep it in its original labeled container when possible.
- I will not give, sell, trade, or share this medication with anyone else. Doing so is dangerous and illegal.
- I am responsible for keeping my medication safe. Lost, stolen, damaged, or destroyed medication will generally NOT be replaced early. If medication is stolen, I will file a police report and provide a copy to my provider.
Refills
- Refills will be provided only during scheduled office visits or as arranged in my treatment plan; not after hours, on weekends, or on holidays.
- I will request refills at least 7 business days before I run out. Early or emergency refills are not guaranteed.
- I understand I must keep my scheduled appointments and required follow-ups to continue receiving prescriptions and I will comply with recommended monitoring for safest practice.
- I understand Nervana has a max ceiling of what they will prescribe and if my care is affected by this dose max, then I will need to terminate all controlled substance refills with Nervana and find another clinician willing to take over my care of controlled substances. *If you have questions about our dose ceilings, please contact our office.
Monitoring (Database, Testing & Pill/Dose Counts)
- I consent to my provider checking the state Prescription Drug Monitoring Program / Controlled Substance Database (in Utah, the Controlled Substance Database “CSD”) to review my controlled-substance prescription history.
- I agree to random or scheduled drug screening (urine, blood, or saliva) when requested, and I understand refusal may be treated the same as a positive or inconsistent result.
- I agree to bring in my medication for a pill/dose count when requested, usually within 24–48 hours of being asked.
- I understand that unexpected results such as the absence of the prescribed medication, or the presence of non-prescribed controlled substances or illicit drugs may result in changes to or discontinuation of my treatment.
Consent to Communicate
I authorize Nervana Medical and its providers to communicate about my controlled-substance treatment with my pharmacy, my primary care provider, other treating clinicians, and, where appropriate, my emergency contact, in order to coordinate care and ensure my safety.
Risks, Benefits & Pregnancy
- I have discussed the expected benefits, common side effects, and serious risks of this medication with my provider, including the risk of tolerance, physical dependence, addiction, and for some medications, respiratory depression or overdose.
- I understand that stopping some controlled substances suddenly can cause withdrawal, and that my medication may need to be tapered under provider guidance.
- If I am able to become pregnant: I will tell my provider if I am pregnant or planning to become pregnant, as some of these medications can harm a developing baby. I will use an effective method of contraception if advised to do so.
Patient Responsibilities Summary
I understand and agree that I will:
- Take the medication exactly as prescribed and keep it safe and secure.
- Use one provider and one pharmacy for controlled substances.
- Keep all appointments and complete required monitoring, testing, and counts.
- Be honest about my symptoms, my use of this and all other substances, and any problems I experience.
- Treat clinic and pharmacy staff with respect.
What May End This Agreement
My provider may change my treatment plan, taper me off the medication, or stop prescribing controlled substances if, for example:
- I do not follow this agreement.
- Monitoring, testing, or counts show inconsistent or concerning results.
- I obtain controlled substances from other providers without disclosure, or alter/forge a prescription.
- The medication is no longer safe or helpful for me, or the risks come to outweigh the benefits.
If controlled-substance prescribing is stopped, my provider will not abandon my care: I will be offered a safe taper where medically appropriate, treatment for withdrawal if needed, and referral to other care or resources.
Acknowledgment
I have read this agreement (or had it read to me), I have had the chance to ask questions, and my questions have been answered to my satisfaction. I understand and voluntarily agree to its terms. I understand that violating this agreement may result in changes to, or discontinuation of, my controlled-substance treatment.
Patient Signature: ____________________________________ Date: ____________
Patient Name (printed): ____________________________________
Want a printable copy?
Download the full Controlled Substance Agreement & Treatment Plan (PDF)