PATIENT STATEMENT

ISSUES CONCERNING CONTROLLED SUSTANCES FOR PAIN

Your Name: ___________________________________________

Today’s Date: _________________________________________

Please tell us all facts, including dates and names of other individual involved, if applicable. You will not be allowed to see your health care provider until you complete this form and sign in the space designated below.

After you return the complete form, return it to the receptionist and he/she will let your health care provider (or a member of your health care team) know you are ready to be seen and to discuss the information you have written.

Patient Signature: _____________________________________________

Printed Name and signature of any individual who assisted you in preparing this form: _____________________________________________________

Received by (medical staff):_______________________________________

Decision: ______________________________________________________

Other pertinent treatment plan information: ____________________

_______________________________________________________