This agreement is essential to the trust and confidence necessary between a patient and the Mid-Valley Pain Clinic. The goals of treatment are not to eliminate pain but to manage my pain in order to improve my ability to function.
Patient Rights: As a person with pain, I have the right to:
- Have my reports of pain taken seriously. My reports are the best indicator of the amount of pain present.
- Have my pain assessed and treated appropriately.
- Actively participate in decisions about managing pain.
- Be treated with dignity and respect by all medical personnel.
- Have my acute pain episodes managed with additional treatment options if indicated.
1.___I will attend all appointments, group meetings, and consultations as requested by my providers. I will follow my pain management treatment plan as prescribed.
2.___I agree to participate to the best of my ability in programs designed to improve my pain such as: yoga, exercise physical therapy, behavioral modification, psychological aspects of pain management, counseling therapy, stress reduction program, pain coping skills, or nutrition.
3.___I will obtain all of my prescribed pain medications only from my primary care provider and will follow our agreements about using these medications.
4.___I should be aware that providers may, by law, share information with other healthcare providers about my care. Information about my pain control progress, medication side effects and recommended modifications to my medication protocol will be discussed with my medical providers including my doctor, insurance provider, hospital, pharmacy or any other appropriate providers.
5.___ To assure safe use of opioids, I agree to drug screening upon provider request. Opioids and treatment by Mid-Valley Pain Clinic may be discontinued if the results are not consistent with prescribed medications.
6.___I will notify my providers if I become pregnant or if my health changes in any way that may impact my treatment plan.
7.___I have the right to discontinue participation in the Mid-Valley Pain Clinic Program at any time for any reason.
If I am unable to follow the guidelines listed in this document, Mid-Valley Pain Clinic may discontinue my participation in their program at any time. My other health care providers will be informed and may continue treatment as deemed appropriate.
This agreement is entered into on: ______________ (date):
Patient signature: ________________________________