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