Prescription Refills

To help quickly take care of your medication needs please fill out the form below with all your current information. You can be asked prior to picking up your medications to see the doctor in an office visit or submit to urine drug screening. You can review our pain management agreement by clicking on the link. Medications refills can take up to 72 hours. You can submit only once during the seventy-two (72) hour period for a refill. We will contact you when your written prescription is ready to be picked up. You MUST have ID when picking up medications from the office.

Name

DOB

Phone

Name Of Medication / Quantity

Pharmacy

Pharmacy Phone Number

Pain Management Agreement

With the offices of Grossinger Neuropain Specialist

The purpose of this Agreement is to prevent misunderstandings about medications you will be taking for pain management. This is to help both you and your doctor to comply with the law regarding controlled pharmaceuticals.

This Agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my doctor undertakes to treat me based on this Agreement.
Understand that if I break this Agreement, that the doctor will stop prescribing these pain-control medicines and will discharge me from the practice. I will return to my family doctor for alternative pain management doctor. Also a drug-dependence treatment program may be recommended.

Communicate fully with the doctor about the character and intensity of your pain, the effect of the pain on your daily life, and how well the medicine is helping to relieve the pain. Let the doctor know about every medication your are taking for any reason.

Do will not attempt to obtain any controlled medicines, including opioid pain medicines, controlled stimulants, or antianxiety medicines from any other practice, unless Dr. Grossinger’s office and the doctor are aware and agree to such medications being prescribed by more than one practice. If you do, you will not receive any narcotic medication from Grossinger Neuropain Specialist.

Safeguard your pain medicine from loss or theft. Lost or stolen medicines will not be replaced.

Use one pharmacy for pain medications. So the doctor can easily keep track of your medications. Multiple pharmacy use is break in contract. You will not receive any narcotic medication from Grossinger Neuropain Specialist.

No refills will be available during evenings or on the weekends. Refill of medication will be called in five (5) days prior to running out. Call earlier if holiday or office closing is possible.

You cannot call more than once during any twenty-four (24) hour period for a refill.You will not come into the office for refills or medical evaluation without prior appointment or being contacted by our office.

You must comply with any random drug test that the doctor or his associates feel necessary. A refusal of any test will mean the doctor may stop prescribing medication and release you from the practice. Further prescriptions will be decided by the results of the test. Understand that this test is performed to check for illegal drug use, over use of medications, or the use of other prescription drugs NOT prescribed by the doctor.

Any threats or abusive attitude toward the office staff or doctor will mean immediately expulsion from the practice and no further medications refills will be provided.
Undergoing this aggrement authorizes the doctor and your pharmacy to cooperate fully with any city, state, or federal law enforcement agency, including this state’s Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medicine. The doctor may provide a copy of this Agreement to your pharmacy. You agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations.

You will use my medicine at a rate no greater than the prescribed rate and that use of my medicine at a greater rate will result in my being without medication for a period of time. If I accelerate dosing, I will not receive refills in advance of the scheduled refill date.

If you violate the guidelines within this agreement, understand that the doctor will stop prescribing the controlled medications.
Understand that you signed this aggreement prior to receiving any medications from Grossinger Neuropain Specialist.