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:
Physical therapy/exercise _______________________________________________
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