Pain Management Health Center

Your Pain Treatment Agreement

Sample Termination Clauses

A. The doctor may terminate this agreement at any time if he/she has cause to believe that I am not complying with the terms of this agreement, or to believe that I have made a misrepresentation or false statement concerning my pain or my compliance with the terms of this agreement.

B. I understand that I may terminate this agreement at any time.

If the agreement is terminated, I will not be a patient of Dr. _____________________ and would strongly consider treatment for chemical dependency if clinically indicated.

 ______________________________     ______________

Patient Signature                        Date

 ______________________________     ______________

Physician Signature                    Date

 ______________________________     ______________

Witness Signature                       Date