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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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