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Pharmacist-patient agreement forms

The pharmacist–patient treatment agreement addresses dispensing hours and observed dosing procedure. It also helps pharmacists to discuss concerns and implications around alcohol and other sedating drug use with patients at the start of their treatment program and to minimize the chance of patients presenting to the pharmacy intoxicated.

When dispensing take-home doses for the first time, the pharmacist should discuss the safe use and storage of the medication with the patient and document this discussion. Pharmacists are encouraged to have patients sign a written agreement, such as the samples provided here, to ensure that precautionary measures and expectations are clearly understood.

These forms are reproduced from Opioid Agonist Maintenance Treatment: A pharmacist's guide to methadone and buprenorphine for opioid use disorder

Source:  Isaac, P., Janecek, E, Kalvik, A. & Zhang, M. (2015). Opioid Agonist Maintenance Treatment: A pharmacist's guide to methadone and buprenorphine for opioid use disorder. Toronto: Centre for Addiction and Mental Health.

© 2015 Centre for Addiction and Mental Health