TO THE PATIENT: As a patient, you have the right to be informed about your condition and the recommended medical or diagnostic procedure or drug therapy to be used, so you may make the informed decision whether or not to take the drug after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you, but rather it is an effort to make you better informed so that you may give or withhold your consent to the drug(s) recommended to you by me, as your physician.
CONSENT TO TREATMENT AND/OR DRUG THERAPY voluntarily request Dr. Konstantin Tsymbalov as my physician, and such associates, technical assistants, nurses and other health care providers as it may deem necessary or advisable, to treat my condition which has been explained to me as: chronic pain. I hereby authorize and give my voluntary consent to administer or follow prescribed prescription(s), controlled substance(s), or narcotic medication(s) as an element in the treatment of my chronic pain.
It has ben explained to me that these medication(s) include narcotic drug(s), which can be harmful if taken without medical supervision. I further understand that these medication(s) are addictive and may, like other drugs used in the practice of medicine, produce adverse effects or results. The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me as listed below. I understand that this listing is not complete, and that it only describes the most common side effects or reactions, and that death is also a possibility as a result from taking these medication(s).
I understand that I will undergo medical tests and examinations before and during my treatment at Back to Life Pain Center. Those tests include random unannounced urine and/or blood test for drugs and I hereby give permission to perform the tests or my refusal may lead to termination of treatment with controlled substances. Presence of unauthorized substances may result in my discharge from Back to Life Pain Center.
For Female patients only: To the best of my knowledge, ___________ I am pregnant ___________ I am not pregnant
If I am not pregnant, I will use appropriate contraception during my course of treatment. I promise to inform my doctor and/or his/her appropriately authorized assistant(s) immediately if I become pregnant during the course of treatment.
If I am pregnant, in addition to the possible risks involved with the long-term use of narcotic(s) and controlled substance(s), I further understand that information on the effects of narcotic(s) and controlled substance(s) on pregnant women and their unborn children is at present inadequate to guarantee that I may not produce significant or serious side effect(s) to my unborn child.
It has been explained to me and I understand that narcotic(s) and controlled substance(s) are transmitted to the unborn child and will cause physical dependence. Thus, if I am pregnant and suddenly stop taking narcotic(s) and controlled substance(s), I or the unborn child may show signs of withdrawal, which may adversely affect my pregnancy or the child. I shall use no drugs without approval, since these drugs particularly as they might interact with narcotic(s) and controlled substance(s), may harm me or my unborn child.
I shall inform any other doctor who sees me during my present or any future pregnancy or who sees the child after birth, of my current or past participation in a chronic, intractable pain program in order that he/she may properly take care of my child and me.
It has been explained to me that after the birth of my child I should not nurse the baby because narcotic(s) and controlled substance(s) are transmitted through the milk to the baby and this may cause physical dependence on narcotic(s) and controlled substance(s) in the child. I understand that for a brief period following birth, the child may show temporary irritability or other ill effects due to my use of narcotic(s) and controlled substance(s). It is essential for the child’s physician to know of my participation to know of my participation in a narcotic(s) and controlled substance(s) treatment program so that he may provide appropriate medical treatment for the child.
All of the above possible effects of narcotic(s) and controlled substance(s) have been fully explained to me and I understand that at present, there have not been enough studies conducted on the long-term use of the drug to assure complete safety to my child. With full knowledge of this, I consent to tits use and hold Back to Life Pain Center and its physicians and all staff harmless for injuries to the embryo/fetus/baby.
MOST COMMON SIDE EFFECTS: constipation, nausea, vomiting, excessive drowsiness, itching, urinary retention, insomnia, depression, impairment of reasoning and judgement, respiratory depression (slow or no breathing), impotence, tolerance to medication(s), physical and emotional dependence or even addiction, and death. I understand that it may be dangerous for me to operate an automobile or other machinery while using these medications and I may be impaired during all activities, including work.
The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me, and I still desire to receive narcotic(s) for the treatment of my chronic, intractable pain.
The goal of this treatment is to help me gain control of my chronic pain in order to live a more productive and active life. I realize that the goal of taking narcotic(s) on a regular basis is to reduce (but probably not eliminate) my pain so that I can enjoy an improved quality of life. An appropriate treatment goal may even mean the eventual withdrawal from the use of all narcotic(s). I realize that the treatment for some will require prolonged or continuous use of controlled medication(s) and that my condition will be evaluated on an individual basis.
I understand that I may withdraw from this treatment plan and discontinue the use of medication(s) at any time, and I will be afforded detoxification under medical supervision.
The drug therapy that my physician may prescribe for me may involve using a drug that the Federal Food and Drug Administration may not have been asked by the manufacturer to review for safety or effectiveness for your condition. Current medical literature shows that such “off label” use may be beneficial to some patients and I understand that recommended dosages for treating intractable pain are often exceeded in order to balance the benefit and risk to the patient.
I understand that no warranty or guarantee has been made to me as to result of any drug therapy or cure of any condition. I have been given the opportunity to ask questions about my condition and treatment, risks of non-treatment and the drug therapy, medical treatment or diagnostic procedure(s) to be used to treat my condition, and the risks and hazards of such drug therapy, treatment and procedure(s), and I believe that I have sufficient information to give this informed consent.
I am aware that certain other medicines such as nalbuphine (Nubain), pantazocine (Talwin), buprenorphine (Buprenex), and butorphanol (Stadol), may reverse the action of the medicine I am using for pain control. Taking any of these other medicines while I am taking my pain medicines can cause symptoms like a bad flu, called a withdrawal syndrome. I agree not to take any of these medicines and to tell any other doctors that I am taking an opioid as my pain medicine and cannot take any of these medicines listed above.
I am aware that addiction is defined as the use of a medicine even if it causes harm, having cravings for a drug, feeling the need to sue a drug and a decreased quality of life. I am aware that the development of addiction has been rarely noted in medical journals and is much more common in a person who has a family or personal history of addiction. I agree to tell my doctor my complete and honest personal drug history and that of my family to the best of my knowledge.
I understand that physical dependence is a normal, expected result of using these medicines for a long time. I understand that physical dependence is not the same as addiction. I am aware that physical dependence means that if my pain medicine use is markedly decreased, stopped or reversed by some of the agents mentioned above, I will experience a withdrawal syndrome. This means I may have any of all of the following: runny nose, yawning, large pupils, goose bumps, abdominal pain and cramping, diarrhea, irritability, aches throughout my body and a flu-like feeling. I am aware that opioid withdrawal is uncomfortable but not life threatening.
I am aware that tolerance to analgesia means that I may require more medicine to get the same amount of pain relief. I am aware that tolerance to analgesia does not seem to be a big problem for most patients with chronic pain; however, it has been seen and may occur to me. If it occurs, increasing doses may not always help and may cause unacceptable side effects. Tolerance or failure to respond well to opioids may cause my doctor to choose another form of treatment.
CONTROLLED SUBSTANCES AGREEMENT: This informed consent also contains the following important requirements that I must fulfill in order to participate in the Chronic Pain Treatment Program.
This agreement relates to my use of any controlled substance(s) (i.e., Narcotics, painkillers, prescription medications) for chronic pain prescribed by Back to Life Pain Center and/or any appropriately authorized ancillary personnel at its office(s). I understand that there are federal and state laws, regulations and policies regarding the use and prescribing of controlled substance(s). The Georgia Department of Health has specific requirements for the use of controlled substance(s) for the treatment of chronic pain.
Therefore, controlled substance(s) will only be provided so long as I am actively participating in Orthopaedic Associates Treatment Program and adhere to the rules specified in this Agreement.
My doctor and/or any appropriately authorized ancillary personnel may at any time discontinue the narcotic prescription(s) at his/her discretion. My progress will be periodically reviewed and, if the narcotics are not improving my quality of life, the narcotics will be discontinued. I will disclose to Back to Life Pain Center drugs I take at any time, prescribed by any physician.
In the event that my doctor and/or any appropriately authorized personnel discontinue my medication and start me on another medication, the discontinued medication will need to be turned into my local police department and a copy of the receipt from the police department will need to be turned into Back to Life Pain Center prior to receiving any new medications.
The therapies necessary to treat my chronic pain have been explained to me and I understand that the therapies will involve my taking daily dosage(s) or narcotic(s), which will help to control my chronic, intractable pain.
I will use the medication(s) exactly as directed by my doctor and/or his appropriately authorized ancillary personnel. I agree not to share, sell or otherwise permit others, including my family and friends, to have access to these medications. I will not participate in the diversion of my medications for illegal use; nor will I give or sell them to anyone else. I understand that I am responsible for keeping all pain medications out of reach of any children inside and outside of the house due to possible side effects for the children and possible injury including intoxication, nerve damage and possible death.
All controlled substances must be obtained at the same pharmacy, when possible. Should the need arise to change pharmacies; I agree to inform Back to Life Pain Center. I will use only one pharmacy and I will provide my pharmacist a copy of this agreement.
I authorize my doctor, and his/her appropriately authorized ancillary personnel to release my medical records to my pharmacist at his/her discretion. I also authorize any pharmacy that I am receiving medications from to release my medical records to Back to Life Pain Center.
Pharmacy Name and Address: ___________________________________________ Phone: ______________________
I understand that my medication(s) will be refilled on a regular basis. I understand that my prescription(s) and my medication(s) are exactly like money. If either are lost or stolen, they WILL NOT BE REPLACED. I FURTHER UNDERSTAND THAT ANY REPLACEMENT OF LOST OR STOLEN MEDICATIONS IS COMPLETELY AT THE DISCRETION OF MY TREATING PHYSICIAN. Otherwise, I will need to wait until my next scheduled refill. I will not seek the same or similar medications from any other source, whether professional or otherwise and if I am prescribed them by another practitioner, I will notify the physician here. In the event that I am arrested or incarcerated related to legal or illegal drugs, refills on controlled substances will not be given.
Refill(s) will not be ordered before the scheduled date. I will not expect to receive additional medication(s) prior to the time of my next scheduled refill, even if my prescription(s) runs out. I agree that refills of my prescription(s) for pain medicine will be given only at the time of an office visit or during regular office hours. No refills will be available during evening hours and/or weekends. The patient or authorized person must be present in person at the office in order to be able to pick up medication script(s). I am aware of the fact that my physician will not call in any pain medication(s) to the pharmacy by phone and/or fax.
I will receive controlled substance(s) or medication(s) only from Back to Life Pain Center doctors and/or their appropriately authorized ancillary personnel unless it is for an emergency or the controlled substance(s) that are being prescribed by another physician are approved by Back to Life Pain Center doctors.
Information that I have been receiving medication(s) prescribed by other doctor, that has not been approved previously by Back to Life Pain Center doctors may lead to a discontinuation of medication(s) and treatment.
Until Back to Life Pain Center and/or their appropriately authorized personnel have gotten to know me and my medical history well, I understand that prescription(s) for larger quantities of medication(s) to cover me while I am out of town will not be given. Later, depending on my compliance, Back to Life Pain Center and/or their appropriately authorized ancillary personnel may modify this, at the sole discretion of the physicians.
If it appears to my doctor and/or his/her appropriately authorized ancillary personnel that there are no demonstrable benefits to my daily function or quality of life from the controlled substance(s), then my doctor and or his/her appropriately authorized ancillary personnel may try alternative medication(s) and/or his/her appropriately authorized personnel, may taper me off of all narcotic(s). I will not hold my doctor and/or any other member of Back to Life Pain Center staff liable for problems caused by the discontinuance of controlled substance(s).
I agree to submit to urine and blood screens to detect the use of non-prescribed and prescribed medication(s) at any time and without prior warning. If I test positive for illegal substance(s), treatment for chronic pain will be terminated and can only be restarted if I am evaluated and treated by an Addictionologist and the Addictionologist recommends continued treatment for chronic pain.
I recognize that my chronic pain represents a complex problem, which may benefit from physical therapy, psychotherapy, behavioral medicine strategies, and surgery. I also recognize that my active participation in the management of my pain is extremely important. I agree to actively participate in all aspects of the pain management program to secure increased function and improved coping with my condition.
I agree that I shall inform any doctor who may treat me for any medical problem that I am enrolled in a narcotic(s) and controlled substance(s) treatment program, since the use of other drug(s) in conjunction with same may cause harm.
I hereby give my doctor and/or his appropriately authorized assistant(s) permission to communicate with the referring physician(s) and any pharmacist(s) regarding my use of controlled substance(s).
I must take the narcotic medication(s) as instructed by my doctor and/or his appropriately authorized assistant(s) or in smaller doses. Any authorized increase in the dose of narcotic medication(s) may be viewed as a cause for discontinuation of the treatment with narcotic medication(s).
All opiate medications prescribed must be brought to each visit. This means I must bring my opiate medication bottles with me to each visit in order for the physician to refill your medication. The medication will then be counted by an authorized Back to Life Pain Center staff member in a sterile manner to ensure that medications are being taken as prescribed and will document those findings in my chart.
If I demonstrate unacceptable behavior patterns, my doctor and/or his/her appropriately authorized assistant(s) may discontinue prescribing the narcotic medication(s) for me.
I must keep all regular follow up appointments as recommended by my doctor and/or his/her appropriately authorized assistant(s).
I agree to be seen/re-evaluated at a minimum of every two months, while receiving controlled substances prescriptions from Back to Life Pain Center.
Evidence of medication hoarding; increasing the amount of medication without communication to my doctor and/or his/her appropriately authorized assistant(s); refilling my prescriptions too frequently; getting the medication from multiple physicians; increasing the amount of the medication despite significant side effects; altering prescriptions; selling, trading, or giving away medication; un-approved use of other drugs (alcohol, sedatives, or suing non-prescription medications inconsistent with drug labeling) during narcotic analgesic treatment; or other unacceptable behavior will results in tapering and discontinuing of narcotic maintenance therapy.
Failure to comply with any of the foregoing conditions may cause discontinuation of narcotic prescription(s) and/or your discharge from the care and treatment by Back to Life Pain Center. Discharge may be immediate for alleged criminal behavior.
I certify and agree to the following:
I am not currently abusing illicit or prescription drug(s) and I am not undergoing treatment for substance dependence or abuse. I am reading and making this agreement while in full possession of my faculties and not under the influence of any substance that might impair my judgement.
I have never been involved in the sale, illegal possession, diversion or transport of controlled substance(s) (narcotics, sleeping pills, nerve pills, or painkillers) or illegal substances (marijuana, cocaine, heroin, etc.) No guarantee or assurance has been made as to the results that may be obtained from chronic pain treatment. With full knowledge of the potential benefits and possible risks involved, I consent to chronic pain treatment, since I realize that I would otherwise continue to have chronic pain.
I wave the right of confidentiality for any federal authorities, local police or DEA in any formally initiated investigations related to the management of any controlled substances.
I have reviewed the Narcotic Side Effects Information that may be used in the treatment of my chronic pain. I fully understand the explanation regarding the benefits and the risks of this method. I agree to the use of narcotic medication(s) in the treatment of my chronic pain.