Narcotic Agreement



Patient Address

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The following policy is designated for ALL patients receiving medications in the form of controlled substances (i.e. narcotics/opiates, sedatives, benzodiazepines, etc.) from Southern Grace Pain & Regenerative Medicine.


Please carefully read the following document to confirm you understand and comply with the statement listed.


  • I understand that I may obtain narcotic prescriptions ONLY from the physician at Southern Grace Pain & Regenerative Medicine. It is illegal for a patient to obtain controlled substances from more than one physician.
  • I agree NOT to ask for narcotic medication prescriptions from ANY other doctor without the knowledge and assent of my physician at Southern Grace Pain & Regenerative Medicine, this includes the emergency room.
  • I agree to keep all scheduled appointments, not just with my provider at Southern Grace Pain & Regenerative Medicine, but also with any and all recommended therapists and psychological counselors.
  • I agree to provide regular urine samples for drug screens. Positive tests for any illegal substances, or narcotics NOT given by the provider at Southern Grace Pain & Regenerative Medicine, may result in loss of prescription privileges, dismissal and/or referral elsewhere for substance abuse evaluation and management.
  • I understand that prescriptions will NOT be refilled early.
  • I understand that I may NOT receive a replacement prescription if I lose, destroy or have medications stolen.
  • I understand that prescription refills will be authorized ONLY during regular office hours.
  • I understand that Southern Grace Pain & Regenerative Medicine will NOT mail prescriptions.
  • I understand that I may pick up a prescription in person, but must call 2 (two) working days in advance of the renewal date.
  • I understand that if I am taking chronic narcotic medications, I should NOT drink alcohol.
  • I understand that narcotic medications cannot be called into a pharmacy for a refill prescription.
  • I understand that there will be NO dosage changes made to my medications without an office visit and evaluation by a provider at Southern Grace Pain & Regenerative Medicine.
  • I understand that I can ONLY use one (1) pharmacy to obtain my narcotic medications.
  • I agree to fully comply with any and all aspects of my treatment program recommended by the providers at Southern Grace Pain & Regenerative Medicine, including behavioral, medical (psychological or psychiatric), interventional therapy and physical therapy.
  • I understand that successful pain management is a multimodal approach including, interventional, active participation in regular exercise and psychological coping strategies. Failure to follow the prescribed treatment plan recommended by the provider at Southern Grace Pain & Regenerative Medicine of any or all of these may lead to discontinuation of medications and/or referral to another provider or treatment center.
  • I understand that narcotics and benzodiazepines cause impairment in judgment. I will not drive while under the influence of these medications.
  • I understand that if I am or become pregnant while being treated at Southern Grace Pain & Regenerative Medicine I will inform my provider immediately.
  • I understand that if I am pregnant or become pregnant while being treated at Southern Grace Pain & Regenerative Medicine, I will NOT receive medications and all prescriptions must be obtained and approved by my treating obstetrician during my pregnancy.

    Please read the following carefully regarding the risks associated with opiate therapy

    Opiates  (narcotics) may cause drowsiness that can be worsened with alcohol, benzodiazepines and other sedating medications. Do NOT drive or operate machinery. An overdose of these medications can cause severe side effects, even death.

    Opioids MUST ONLY be taken as directed. Federal law prohibits giving these medications to anyone else. Physical dependence will develop with regular use, but does not by itself indicate addiction; this means that a withdrawal syndrome will develop if one stops the medication abruptly. Tolerance may develop to the pain-relieving effects of opioids; this means that the pain relief may decrease over time, but in chronic pain conditions this process occurs slowly.

    Other common, usually temporary, side effects include nausea, itching and sweating. Psychological depression and lowered testosterone levels (especially in men) may also occur.  Sleep apnea, if present may be worsened by opioids. Constipation commonly occurs, and often does not improve with time. It is impossible to predict opioid side effects in any individual patient. Having side effects on one opioid does not necessarily mean there will be side effects on another narcotic medication.

    Most chronic pain conditions do NOT respond to opiate therapy long term. Some pain may only be partially responsive to opiates. Total elimination of pain is an unrealistic goal. Increasing dosages may indicate that opiates are not effective or that there is an underlying problem with addiction or psychological dependence. Discontinuation of opiate medications may need to be done under these circumstances: not enough pain relief, persistent side effects, not achieving goals of opiate therapy (such as improvement of function), problematic dosage increases or inability to comply with the treatment agreement.

    I, the undersigned, agree to follow these guidelines that have been fully explained to me. All of my questions and concerns regarding treatment have been adequately answered.

    I give permission to the staff and physicians at Southern Grace Pain & Regenerative Medicine clinic to contact my other healthcare providers, for the purposes of sharing information concerning my situation, as is deemed necessary for coordinated, high quality care.

    If I do not follow these guidelines fully, the physicians at Southern Grace Pain & Regenerative Medicine may have the right to decline care.

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