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Oregon Pain Center Opioid Agreement

OPC Opioid Agreement

We believe that transparency and strong communication is the key to successful patient encounters. Below you will find the Oregon Pain Center Opioid Agreement, we ask each patient to sign the agreement prior to prescribing and managing their medications. Please let us know at the time of your appointment if you have any questions or concerns.


Effective pain management requires that the patient, physicians and medical staff work together. This agreement is designed to make sure that you understand the rules regarding the use of medications that we will prescribe in your treatment. If you do not understand any part of this agreement, please discuss it again with your clinician at the time of your appointment. It is important that you understand that if do not follow the terms of this agreement, your treatment will be less effective and may be cause for discontinuing treatment and prescribed medications.

Please read and follow this agreement carefully:

  • You must have a primary care provider (PCP).
  • You will treat the staff at the office respectfully at all times. You understand that if you are disrespectful to staff or disrupt the care of other patients your treatment will be stopped.
  • You may fill your initial prescription at the pharmacy of your choice. However, all refills must be made with the same pharmacy.
  • You agree to take your medications as prescribed. If you choose to change the way you are taking your medicine, a follow up appointment to discuss it with the Provider will be required.
  • You agree to take only your own medications. You will not take someone else’s medications even if you think it is the same medicine. You will not share your medications with anyone else.
  • You will keep the medicine safe, secure and out of the reach of children. If the medicine is lost or stolen, you understand it may not be replaced until your next appointment, and may not be replaced at all.
  • You agree that OPC clinicians will be the only clinicians prescribing pain medication and other controlled substances for you. You will let us know about any medicines prescribed for you by any other physician or any other health care provider
  • You agree not to take any street or recreational drugs during the course of your treatment with OPC
  • You agree to advise OPC of any over-the-counter drugs, vitamin supplements, and herbal remedies you are taking. You give consent for on-demand, unscheduled urine toxicology screening (drug testing) on site and/or sent to a third party for confirmation. You will be charged for the urine toxicology screening and charges for a third party confirmation.
  • You give consent for random pill counts based on risk stratification with 48 hours notice.
  • We prescribe enough medication to last until your next visit or next scheduled medication refill date. We will not provide additional refills before the original fill date. You are responsible for notifying us at least three (3) business days before your narcotic medication runs out. You must call during regular office hours for your refills. Refills on medications are not given on an emergency basis. Refills are not given after hours, on weekends, or on holidays.
  • You are required to attend all follow-up appointments scheduled for you. If you need to reschedule the appointment, you must call 48 hours in advance. Please note that if you fail to reschedule your scheduled appointment within the allotted amount of time you will be charged a no-show/cancellation fee of $50 for a follow up appointment and $100 for a procedure. Failure to keep follow-ups in a timely manner, may affect prescription refills and may result in clinic discharge.
  • While being prescribed opioids you may not use Ambien, Benzodiazepines (Ativan, Valium, Xanax, etc), or medical cannabis (marijuana, CBDs) in any form (inhaled, topical, oils, edibles), even if prescribed by another physician, unless approved in writing by one of our providers.
  • You may not use alcohol