Pain Treatment Agreement Letter Samples

Sample -1

I am writing to inform you that your request for the treatment of opioids for pain treatment has been approved. I am sharing the terms and conditions with you. Kindly go through them and read them thoroughly to understand them. If you agree to all the clauses we can start your treatment from the next week. I case you do not understand the clauses, please do not hesitate to give me a call at my number [x] or visit me during my office hours with a prior appointment.

You are about to undergo medical treatment, it is in your best interest that you may have a comprehensive view of what it is about. Following are the terms and conditions for the pain treatment agreement.

  1. It is hereby stated that Mr. Gabriel Mark will undergo medical treatment through controlled substances under the supervision of Dr George Will. 
  2. It will be a long-term treatment starting from 5th October 20xx till the date doctor decides to prolong it. 
  3. During the treatment, the patient will not be allowed to use any other medication or see any other doctor without prior permission from Dr George Will.
  4. The appointments will be regular and will not be shifted or rescheduled by any means. However, if the doctor or patient is not available, both are liable to tell each other 24 hours in advance.
  5. The patient will be getting all the prescribed medication only from one pharmacy which is [x]. The doctor will discuss the case of the patient with the pharmacist for the regular supply of medicine. The patient is not allowed to change the pharmacy on his own. 
  6. If the patient is disrespectful towards the doctor or other medical staff, his treatment will be stopped immediately.
  7. In case the patient is not comfortable with the treatment or not getting effective results, he may terminate the agreement but medication will be stopped by the doctor only so it will not create a problem for the patient health-wise. 

Kindly let us know when you are ready to sign the agreement so we start the medical procedure. I look forward to hearing from you soon. Thank you for your cooperation. 

Pain treatment agreement letter

Sample -2

I am writing to inform you that your case has been shortlisted for opioid pain treatment. However, there are a few conditions that you need to abide by in case you want to continue your treatment with me. I am sharing all the clauses with you. Kindly read them with great care and let me know when you are ready for the treatment. You can write me back at [x] or give me a call on my number [x].

In case you do not understand a medical term, you may also visit me tomorrow at 4:00 pm in my office. It is your legal right to be clear regarding the medical procedure. The terms and conditions are as follows:

  1. It will be short-term or long-term treatment based on the opinion of the doctor. However, the patient cannot take any other medication or visit any other consultant without the advice of his doctor. 
  2. The patient will strictly be using only one pharmacy prescribed by the doctor to get his medicine. 
  3. The patient will not share his prescription with anyone else.
  4. The patient truly understands that his treatment is being done by using controlled substances. 
  5. The patient will take medication regularly and will not miss a single appointment.
  6. The patient will not stop taking medicine on his own unless advised by the doctor. 
  7. The refills will be made on the scheduled days. No extra refills will be given to the patient even if the medicine is wasted or stolen. The patient is solely responsible for it. 
  8. This agreement will be terminated only by the doctor. In case the patient is not comfortable using the medication, he should inform the doctor immediately. 

Kindly read all the clauses. After signing the agreement, we will start your treatment in a week. I look forward to hearing from you soon. Thank you for your understanding.


Pain treatment agreement letter

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