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Pain Management Health Center

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Your Pain Treatment Agreement

An Example of a Pain Treatment Agreement continued...

My treatment plan may change based on outcome of therapy, especially if pain medications are ineffective. Such medications will be discontinued.
My treatment plan includes:

Medications ______________________________________________________

Physical therapy/exercise _______________________________________________

Relaxation techniques_______________________________________________

Psychological counseling _______________________

I understand that Dr. ____________________________ believes in the following "Pain Patients Bill of Rights."

You have the right to:

  • Have your pain prevented or controlled adequately.
  • Have your pain and medication history taken.
  • Have your pain questions answered.
  • Know what medication, treatment or anesthesia will be given.
  • Know the risks, benefits, and side effects of treatment.
  • Know what alternative pain treatments may be available.
  • Ask for changes in treatments if your pain persists.
  • Receive compassionate and sympathetic care.
  • Receive pain medication on a timely basis.
  • Refuse treatment without prejudice from your physician.
  • Include your family in decision-making.

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

WebMD Medical Reference

Reviewed by Jennifer Robinson, MD on August 27, 2015
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