Skip to content

Pain Management Health Center

Font Size

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

WebMD Medical Reference

Reviewed by Arefa Cassoobhoy, MD, MPH on August 01, 2013
1|2

Today on WebMD

pain in brain and nerves
Top causes and how to find relief.
knee exercise
8 exercises for less knee pain.
 
acupuncture needles in woman's back
How it helps arthritis, migraines, and dental pain.
chronic pain
Get personalized tips to reduce discomfort.
 
illustration of nerves in hand
Slideshow
lumbar spine
Slideshow
 
Woman opening window
Slideshow
Man holding handful of pills
Video
 
Woman shopping for vegetables
Slideshow
Sore feet with high heel shoes
Slideshow
 
acupuncture needles in woman's back
Slideshow
man with a migraine
Slideshow