Healthcare Opioid Consent Form

Healthcare Opioid Consent Form

Patient Information

Date of Birth:    Gender:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History

History of substance use disorder: Yes    Current use of benzodiazepines or sedatives: Yes

Treatment Plan and Medication Details

Strength / Formulation:    Directions for Use:

Quantity Prescribed:    Refills Authorized:

Treatment Start Date:    Expected Duration:

Risks, Benefits and Alternatives

I understand that the prescribed opioid medication is intended to treat pain and that benefits may include reduction of pain and improved function. I have been informed of common and serious risks, including but not limited to: respiratory depression (which can be fatal), sedation, constipation, nausea, tolerance, physical dependence, opioid use disorder (addiction), and impaired ability to operate machinery or drive.

Alternatives to opioid therapy have been discussed and may include: non-opioid analgesics, physical therapy, topical agents, interventional procedures, and behavioral health interventions. I understand I may decline opioid therapy and pursue alternative treatments.

I acknowledge that the following specific risks were explained to me: Initials for each item:

Respiratory depression and possible death:

Risk of dependence, tolerance, and addiction:

Dangerous interactions with alcohol and sedatives (e.g., benzodiazepines):

Agreements and Conditions of Opioid Therapy

In consideration of receiving opioid medication, I agree to the following conditions which are necessary for continued prescribing:

1. Use the medication only as prescribed and not in greater amounts or more frequently than directed.
2. Not to share, sell, or distribute the medication. I understand that sharing medication is illegal and dangerous.
3. Store medications securely and out of reach of children; dispose of unused medication safely.
4. Consent to periodic urine drug screening, pill counts, and prescription monitoring checks as requested by my prescriber. Consent is required for continuation of therapy.
5. Notify my prescriber of any adverse effects, pregnancy, or use of other controlled substances, alcohol, or sedatives.
6. I understand that early refills will not be provided for lost, stolen, or destroyed medications and that lost or stolen medications will not be replaced except under rare documented circumstances.
7. Noncompliance with these conditions, diversion of medication, or positive tests for unexpected controlled substances may result in reduction or discontinuation of opioid therapy and possible discharge from the practice.

I consent to random or scheduled urine drug screening: Yes    I consent to periodic pill counts: Yes

Privacy and Information Sharing

I acknowledge that the information contained in my medical record, including records of controlled substance prescribing, may be shared with other health care providers, pharmacies, and authorized entities for the purposes of treatment, payment, and as required by law. I understand that certain disclosures may be made to the state prescription monitoring program as required by statute.

I acknowledge receipt of counseling regarding opioid risks, safe use, storage, and disposal: Yes

Authorization Expiration; Withdrawal of Consent

This consent and agreement applies to current and future opioid prescriptions related to the indicated condition until:

I understand I have the right to withdraw consent to opioid therapy at any time by notifying my prescriber; withdrawal of consent may result in discontinuation of opioid prescriptions and referral to alternative pain management.

Patient Certifications

By signing below I certify that I have read and understand the information on this form, that my questions have been answered, and that I agree to comply with the conditions herein. I understand the potential benefits and significant risks, including the risk of addiction, overdose, and death.

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