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ADHD TREATMENT AGREEMENT

ADHD Treatment AgreementMichael2021-02-25T08:30:01-06:00

Patient's Name*
First Last
Patient's Date of Birth*
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
Enter Email Confirm Email
Date*
Date Format: MM slash DD slash YYYY
Signature of Parent or Legal Guardian*

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