Common use of UNDERSTAND AND AGREE TO THE FOLLOWING Clause in Contracts

UNDERSTAND AND AGREE TO THE FOLLOWING. That this pain management agreement relates to my use of any and all medication(s) (i.e., opioids, also called ‘narcotics, painkillers’, and other prescription medications, etc.) for chronic pain prescribed by my physician. I understand that there are federal and state laws, regulations and policies regarding the use and prescribing of controlled substance(s). Therefore, medication(s) will only be provided so long as I follow the rules specified in this Agreement. • My progress will be periodically reviewed and, if the medication(s) are not improving my quality of life, the medication(s) may be discontinued. I will communicate with my provider at every visit about my pain relief, any side-effects and improvement in quality of life. • I will disclose to my physician all medication(s) that I take at any time, prescribed by any physician including over the counter and other sources. • I will use the medication(s) exactly as directed by my physician. • I agree not to share, sell or otherwise permit others, including my family and friends, to have access to these medications. I will not allow or assist in the misuse/diversion of my medication; nor will I give or sell them to anyone else. I understand that it is against the law to do so. • All medication(s) must be obtained at one pharmacy, where possible. Should the need arise to change pharmacies, my physician must be informed. I will use only one pharmacy and I will provide my pharmacist a copy of this agreement. I authorize my physician to release my medical records to my pharmacist as needed. I will inform my physician of a change in pharmacy immediately. • I understand that my medication(s) may be refilled on a regular basis. I fully understand that my medications if lost or stolen, may NOT BE REPLACED. I understand that I am required to file a police report before being considered for further treatment. • Refill(s) will not be ordered before the scheduled refill date. However, early refill(s) may be allowed by my physician when I am traveling and I make arrangements in advance of the planned departure date. Otherwise, I will not accept or request controlled substance medication from any other person or health care provider. If I do so, I may be discharged from the clinic. • I will receive medication(s) only from ONE physician unless it is for an emergency or the medication(s) that is being prescribed by another physician is approved by my physician. Information that I have been receiving medication(s) prescribed by other doctors that has not been approved by my physician may lead to a discontinuation of medication(s) and treatment. • If it appears to my physician that there are no demonstrable benefits to my daily function or quality of life from the medication(s), then my physician may try alternative medication(s) or may taper me off all medication(s). I will not hold my physician liable for problems caused by the discontinuance of medication(s). • I agree to submit to urine and/or blood tests 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), such as marijuana, speed, cocaine, etc., treatment for chronic pain may be terminated. Also, I understand that I will have to comply with a consult with, or referral to, an expert: such as submitting to a psychiatric or psychological evaluation by a qualified physician such as an addictionologist or a physician who specializes in detoxification and rehabilitation and/or cognitive behavioral therapy/psychotherapy. • I recognize that my chronic pain represents a complex problem which may benefit from physical therapy, psychotherapy, alternative medical care, etc. 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 recommended by my physician to achieve increased function and improved quality of life. I understand that my physician may terminate my treatment if I am not compliant. • I agree that I shall inform any doctor who may treat me for any other medical problem(s) that I am enrolled in a pain management program, since the use of other medication(s) may cause harm. • I hereby give my physician permission to discuss all diagnostic and treatment details with my other physician(s) and pharmacist(s) regarding my use of medications prescribed by my other physician(s). • I must take the medication(s) as instructed by my physician. Any unauthorized increase in the dose of medication(s) may be viewed as a cause for discontinuation of the treatment. • I must keep all follow-up appointments as recommended by my physician or my treatment may be discontinued. I will not call at the end of the day or on weekends for unscheduled medication refills.

UNDERSTAND AND AGREE TO THE FOLLOWING. That this pain management agreement relates to my use of any and all medication(s) (i.e., opioids, also called ‘narcotics, painkillers’, and other prescription medications, etc.) for chronic pain prescribed by my physician. I understand that there are federal and state laws, regulations and policies regarding the use and prescribing of controlled substance(s). Therefore, medication(s) will only be provided so long as I follow the rules specified in this Agreement. • My progress will be periodically reviewed and, if the medication(s) are not improving my quality of life, the medication(s) may be discontinued. I will communicate with my provider at every visit about my pain relief, any side-effects and improvement in quality of life. • I will disclose to my physician all medication(s) that I take at any time, prescribed by any physician including over the counter and other sources. • I will use the medication(s) exactly as directed by my physician. • I agree not to share, sell or otherwise permit others, including my family and friends, to have access to these medications. I will not allow or assist in the misuse/diversion of my medication; nor will I give or sell them to anyone else. I understand that it is against the law to do so. • All medication(s) must be obtained at one pharmacy, where possible. Should the need arise to change pharmacies, my physician must be informed. I will use only one pharmacy and I will provide my pharmacist a copy of this agreement. - I authorize my physician to release my medical records to my pharmacist as needed. I will inform my physician of a change in pharmacy immediately. • I understand that my medication(s) may be refilled on a regular basis. I fully understand that my medications if lost or stolen, may NOT BE REPLACED. I understand that I am required to file a police report before being considered for further treatment. • Refill(s) will not be ordered before the scheduled refill date. However, early refill(s) may be allowed by my physician when I am traveling and I make arrangements in advance of the planned departure date. Otherwise, I will not accept or request controlled substance medication from any other person or health care provider. If I do so, I may be discharged from the clinic. • I will receive medication(s) only from ONE physician unless it is for an emergency or the medication(s) that is being prescribed by another physician is approved by my physician. Information that I have been receiving medication(s) prescribed by other doctors that has not been approved by my physician may lead to a discontinuation of medication(s) and treatment. • If it appears to my physician that there are no demonstrable benefits to my daily function or quality of life from the medication(s), then my physician may try alternative medication(s) or may taper me off all medication(s). I will not hold my physician liable for problems caused by the discontinuance of medication(s). • I agree to submit to urine and/or blood tests 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), such as marijuana, speed, cocaine, etc., treatment for chronic pain may be terminated. Also, I understand that I will have to comply with a consult with, or referral to, an expert: such as submitting to a psychiatric or psychological evaluation by a qualified physician such as an addictionologist or a physician who specializes in detoxification and rehabilitation and/or cognitive behavioral therapy/psychotherapy. • I recognize that my chronic pain represents a complex problem which may benefit from physical therapy, psychotherapy, alternative medical care, etc. 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 recommended by my physician to achieve increased function and improved quality of life. I understand that my physician may terminate my treatment if I am not compliant. • I agree that I shall inform any doctor who may treat me for any other medical problem(s) that I am enrolled in a pain management program, since the use of other medication(s) may cause harm. • I hereby give my physician permission to discuss all diagnostic and treatment details with my other physician(s) and pharmacist(s) regarding my use of medications prescribed by my other physician(s). • I must take the medication(s) as instructed by my physician. Any unauthorized increase in the dose of medication(s) may be viewed as a cause for discontinuation of the treatment. • I must keep all follow-up appointments as recommended by my physician or my treatment may be discontinued. I will not call at the end of the day or on weekends for unscheduled medication refills.

UNDERSTAND AND AGREE TO THE FOLLOWING. That this pain management agreement relates to my use of any and all medication(s) (i.e., i.e. opioids, also called ‘narcotics, painkillers’, and other prescription medications, etc.) for chronic pain prescribed by my physician. I understand that there are federal and state laws, regulations and policies regarding the use and prescribing of controlled substance(s). Therefore, medication(s) will only be provided so long as I follow the rules specified in this Agreement. •  My progress will be periodically reviewed and, if the medication(s) are not improving my quality of life, the medication(s) may be discontinued. I will communicate with my provider at every visit about my pain relief, any side-effects and improvement in quality of life. •  I will disclose to my physician all medication(s) that I take at any time, prescribed by any physician including over the counter and other sourcesphysician. •  I will use the medication(s) exactly as directed by my physician. •  I agree not to share, sell or otherwise permit others, including my family and friends, to have access to these medications.  I will not allow or assist in the misuse/diversion of my medication; nor will I give or sell them to anyone else. I understand that it is against the law to do so. •  All medication(s) must be obtained at one pharmacy, where possible. Should the need arise to change pharmacies, my physician must be informed. I will use only one pharmacy and I will provide my pharmacist a copy of this agreement. I authorize my physician to release my medical records to my pharmacist as needed. I will inform my physician of a change in pharmacy immediately. •  I understand that my medication(s) may will be refilled on a regular basis. I fully understand that my medications if prescription(s) and my medication(s) are exactly like money. If either are lost or stolen, they may NOT BE REPLACED. I understand that I am required to file a police report before being considered for further treatment. •  Refill(s) will not be ordered before the scheduled refill date. However, early refill(s) may be are allowed by my physician when I am traveling and I make arrangements in advance of the planned departure date. Otherwise, I will not accept or request controlled substance medication from any other person or health care providerexpect to receive additional medication(s) prior to the time of my next scheduled refill, even if my prescription(s) run out. If I do so, I may be discharged from the clinic. •  I will receive medication(s) only from ONE physician unless it is for an emergency or the medication(s) that is being prescribed by another physician is approved by my physician. Information that I have been receiving medication(s) prescribed by other doctors that has not been approved by my physician may lead to a discontinuation of medication(s) and treatment. •  If it appears to my physician that there are no demonstrable benefits to my daily function or quality of life from the medication(s), then my physician may try alternative medication(s) or may taper me off all medication(s). I will not hold my physician liable for problems caused by the discontinuance of medication(s). •  I agree to submit to urine and/or blood tests 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), such as marijuana, speed, cocaine, etc., treatment for chronic pain may be terminated. Also, I understand that I will have to comply with a consult with, or referral to, an expert: expert may be necessary; such as submitting to a psychiatric or psychological evaluation by a qualified physician such as an addictionologist or a physician who specializes in detoxification and rehabilitation and/or cognitive behavioral therapy/psychotherapy. •  I recognize that my chronic pain represents a complex problem which may benefit from physical therapy, psychotherapy, alternative medical care, etc. 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 recommended by my physician to achieve increased function and improved quality of life. I understand that my physician may terminate my treatment if I am not compliant. •  I agree that I shall inform any doctor who may treat me for any other medical problem(s) that I am enrolled in a pain management program, since the use of other medication(s) may cause harm. •  I hereby give my physician permission to discuss all diagnostic and treatment details with my other physician(s) and pharmacist(s) regarding my use of medications prescribed by my other physician(s). •  I must take the medication(s) as instructed by my physician. Any unauthorized increase in the dose of medication(s) may be viewed as a cause for discontinuation of the treatment. •  I must keep all follow-up appointments as recommended by my physician or my treatment may be discontinued. I will certify and agree to the following: 1) I am not call at currently using illegal drugs or abusing prescription medication(s) and I am not undergoing treatment for substance dependence (addiction) or abuse. I am reading and making this agreement while in full possession of my faculties and not under the end influence of any substance that might impair my judgment. 2) I have never been involved in the sale, illegal possession, misuse/diversion or transport of controlled substance(s) (narcotics, sleeping pills, nerve pills, or painkillers) or illegal substances (marijuana, cocaine, heroin, etc.) 3) No guarantee or assurance has been made as to the results that may be obtained from chronic pain treatment. With full knowledge of the day or on weekends for unscheduled medication refillspotential benefits and possible risks involved, I consent to chronic pain treatment, since I realize that it provides me an opportunity to lead a more productive and active life. 4) I have reviewed the side effects of the medication(s) that may be used in the treatment of my chronic pain. I fully understand that explanations regarding the benefits and the risks of these medication(s) and I agree to the use of these medication(s) in the treatment of my chronic pain.