Education
Medical Profile
If there is a family history of any of the illnesses listed below, please check the box next to that illness.
Tobacco History
Substance Use History
Infections
(If yes give approximate Age)
Medications
Review of Systems
No Problems
Family History (State Health or Cause of Death in Each)
Office Based Addiction Treatment (OBAT) Program
As a patient in the Office Based Addiction Treatment (OBAT) program, I freely and voluntarily agree to accept this treatment agreement, as follows. I understand the OBAT program in providers, nurses ,care coordinators, medical assistants, and administrative support personnel.
I agree to do my best to arrive on time to all my scheduled appointments. I will call the clinic if I will be late/early or need to reschedule my appointment.
When I am in the clinic, I agree to conduct myself in a courteous and respect manner.
I agree not to sell, share or give any of my medication to others. I understand that any mishandling of my medication may result in a change of my treatment plan including referral to a higher level of care or discharge.
I agree not to conduct any illegal, threatening, or disruptive activities in the clinic or on Dominion HealthCare Services, Inc. campus. I will be discharged or referred to a higher level of care for behaviors that are unsafe or inappropriate.
I agree that it is my responsibility to keep my medication safe and secure at all times. I understand that any lost medication will require an assessment and plan with my team. My medication should be out of the reach and sight of children at all times. I will keep my medication in a container that displays a prescription label. If I carry sealed films on my person, I will do so with a pharmacy label.
I agree to inform my provider and/or OBAT nurse immediately about prescriptions or over the counter medications from any prescribers, pharmacies, or other sources (such as the dentist, emergency department, or psychiatrist).
Per Maryland law, Dominion HealthCare Services, Inc. OBAT will routinely access the Prescription Drug Monitoring Program (PDMP) to review medication profiles. If l am round to be obtaining prescriptions from other providers, the OBAT team will address the circumstances with me, and if necessary, adjust my treatment plan.
I understand that mixing buprenorphine with other substances, especially those that can cause sedation such as benzodiazepines, gabapentin, alcohol, etc. can be dangerous and can increase my risk of overdose and even death.
I agree to take my medication as the provider has instructed and not to adjust the way I take it without first consulting my nurse or provider.
I agree to random call back visits that include urine toxicology screens and medication counts. I understand that I need to have a working telephone. When called by the OBAT team. I will respond within 24 hours by telephone.
I agree not to eat poppy seeds while in treatment. Poppy seed consumption may result in a positive opioid screen.
I understand that if I misuse other substances or medications, the OBAT team will assist me by changing or intensifying my treatment plan. If I continue to struggle with ongoing substance use. I may be transferred to a more intensive setting to meet my treatment needs.
I agree to urine toxicology screenings. I will not tamper with testing. I understand that it is best to be honest with my treatment team if I am struggling and understand the team is here to assist me in my treatment.
Urine screens that are negative for buprenorphine will be evaluated by the OBAT team and toxicologist.
I understand that the Dominion HealthCare Services, Inc. OBAT does not maintain a chain of custody over urine toxicology screens. Dominion HealthCare Services, Inc. OBAT collects urine toxicology tests as medically necessary. Testing that requires chain of custody must occur outside or the OBAT program.
If I am female and of child bearing age and do not plan on becoming pregnant, it is strongly recommended that I utilize contraceptives. If I become pregnant while in treatment, I will alert my OBAT team immediately so they can assist me in connecting with an OB/GYN provider who understands addiction. I will not be discharged from the program.
If I participate in a higher level of treatment or am discharged from OBAT, I may be readmitted at a future time.
I agree to participate in patient education, counseling and relapse prevention programs to assist me in my treatment.
Office Based Addiction Treatment (OBAT) ProgramCONSENT FOR BUPRENORPHINE TREATMENT
Buprenorphine is a medicine that is used to treat opioid use disorder. Buprenorphine is an opioid that can help support recovery because it reduces craving and withdrawal symptoms, and blocks the effects of stronger and more dangerous opioids. Buprenorphine can be taken as a daily under the tongue film/pill, or it can be taken by a monthly shot. This consent form is for daily film or pill.
Buprenorphine is used for maintenance therapy. Maintenance therapy can continue as long as medically necessary, it is recommended that buprenorphine treatment lasts for at least six (6) months.
Buprenorphine contains an opioid that can cause physical dependence. Do not stop taking Buprenorphine suddenly. You may become sick with withdrawal symptoms because your body has gotten used to the medicine. Symptoms of withdrawal may include: muscle aches, stomach cramps, or diarrhea lasting several days. To decrease the possibility of opioid withdrawal, if you plan to stop Buprenorphine it should be done slowly over several weeks or longer under the direction of your care team.
It may take several days to get used to the transition from the opioid that had been taken and using Buprenorphine. During this time any use of other opioids may cause an increase in symptoms. Combining Buprenorphine with alcohol or other sedating medications (such as benzodiazepines, pain medications, sleeping pills, anxiety medicines, antidepressants) may cause overdose and even death. You should not take any other medications without first discussing it with your health care provider.
After becoming stabilized on Buprenorphine, the use of other opioids will have less effect. Attempts to override the Buprenorphine by taking more opioids could result in an opioid overdose.
The form of Buprenorphine that you will be taking is a combination of Buprenorphine and naloxone. If the Buprenorphine /Naloxone tablet were dissolved and injected by someone taking heroin or another strong opioid, it could cause life-threatening infections and severe opioid withdrawal.
To fully absorb the medication, Buprenorphine/Naloxone tablets must be held under the tongue until they completely dissolve. Buprenorphine/Naloxone film must be completely dissolved either under the tongue or on the inside of your cheek. Your treatment team will discuss the proper technique to administer your medication.
I have read this form or had it read to me. I understand what this says. I was given the opportunity to ask questions. All of my questions were answered. I believe l have enough information to consent to buprenorphine treatment. By signing this form I authorize my OBAT clinical team (physician, nurse practitioner, nurse), to treat me with the medication buprenorphine as medically appropriate.
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