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ADHD TREATMENT AGREEMENT
ADHD Treatment Agreement
Michael
2021-02-25T08:30:01-06:00
Patient's Name
*
First
Last
Patient's Date of Birth
*
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Treatment Plan
*
I understand that:behavorial care is not mixed with well or urgent care and my child must have a yearly well care exam and a medication check appointment at least once every three months (minimum of four visits per year).urgent care (cold, sore throat, abdominal pain, etc.) does not replace a three-month medication follow-up appointment.the physician will monitor my child’s symptoms and side effects every 6 months using the Vanderbilt questionnaires.a behavioral screening must be completed at each visit.
Controlled Substances
*
I understand that stimulant medications (Ritalin, Adderall, Concerta, Vyvanse, etc.) are classified as controlled substances by the FDA and closely monitored by the Drug Enforcement Administration (DEA).
BY LAW, these medications:
- CANNOT
be automatically refilled.
- CANNOT
be phoned or faxed to a pharmacy.
- MUST
be picked up in person, with ID verification.
Lost or Stolen Prescriptions
*
I understand that if any of the issued prescriptions for stimulant medications are lost or stolen, a police report MUST be filed and a copy sent to our office BEFORE replacement prescription(s) are issued.
Required Follow-up
*
I understand that my child will need to complete a medication follow-up appointment at least 5 days BEFORE the completion of their medication supply. Additional perscriptions CANNOT be issued until the medication follow-up appointment is completed.
Failure to Comply
*
I understand that if I fail to comply with this agreement, the physician may discontinue medication and/or treatment.
Name of Parent or Legal Guardian
*
First
Last
Relationship to Patient
*
Mother
Father
Email a me copy of this agreement?
*
No
Yes
Email
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Date
*
Date Format: MM slash DD slash YYYY
Signature of Parent or Legal Guardian
*
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