WILLIAM BLANE RICHARDSON, MD

| SOUTHERN GRACE PRECISION & AESTHETICS

WILLIAM BLANE RICHARDSON,MD

SOUTHERN GRACE PRECISION & AESTHETICS

Patients Demographic Form

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PATIENT IS RESPONSIBLE FOR INSURANCE CO-PAYS AND FOR BALANCE NOT COVERED BY THE INSURANCE COMPANY.

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PAYMENT IN FULL WILL BE REQUIRED UPON CHECK-IN AT THE FRONT DESK.

Physician: William Blane Richardson, MD

The following policy is designated for all patients receiving medical care from Southern Grace Pain & Regenerative Medicine.

I. Patients may be required to undergo a urine drug screen upon completion of their initial consultation and evaluation at Southern Grace Pain & Regenerative Medicine.
II. Patients will be required to sign the “Narcotic Agreement” and the “Drug Screen Policy” upon completion of the initial consultation and evaluation at Southern Grace Pain & Regenerative Medicine. if they are to receive medications.
III. Patients will undergo random drug screening while under the care and medical management at Southern Grace Pain & Regenerative Medicine.
IV. Patients will only obtain prescribed controlled substances from Southern Grace Pain & Regenerative Medicine. providers, unless otherwise authorized by the Southern Grace Pain & Regenerative Medicine. provider. This does not pertain to medications for systemic disease states such as hypertension, diabetes, hypercholesterolemia, etc.
V. Patients will obtain prescription from only a single pharmacy.
VI. If there is a discrepancy with a drug screening regarding controlled substances prescribed by Southern Grace Pain & Regenerative Medicine. provider, and or other medications provide by other healthcare providers, Patients will no longer receive medications from the staff at Southern Southern Grace Pain & Regenerative Medicine. provider.
VII. If there is a discrepancy with a drug screen regarding controlled substances and the patient obtains prescription from another medical provider, that provider will be contacted regarding the results of the screening.
VIII. If there is a discrepancy with a drug screening, regarding prescription medications or illegal substances (i.e Cocaine, Marijuana, Amphetamines, LSD, etc.) the patient will no longer receive controlled substances from the practice, a patient may be dismissed from the practice and the proper authorities will be contacted regarding the matter.
IX. Patient agrees to comply fully with all aspects of treatment program including behavior medicine (psychology/psychiatry) and physical therapy, if recommended. Failure to do so may lead to discontinuation or referral to another treatment provider or center.
X. Patient agrees to keep all scheduled appointments, not just with the physician, but also including recommended therapists and psychological counselors. Three (3) or more missed appointments or same day cancellations will lead to patient dismissal from Southern Grace Pain & Regenerative Medicine.. 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 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 providers at Southern Grace Pain & Regenerative Medicine may have the right to decline care and will refer me elsewhere for treatment.
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