FORM-Vivitrol Agreement Vivitrol Agreement Vivitrol Treatment Acknowledgment and Consent(Required)I understand that Dr. Stoudmire is prescribing Vivitrol/Naltrexone to manage my alcohol dependence or opioid dependence. The risks, side effects, and benefits of treatment have been explained to me, and I agree to the following instructions. Failure to follow these instructions may result in not having the medication prescribed. 1. I will participate in any other treatments recommended by my provider, including group therapy. 2. I will take my medications exactly as prescribed and will not change the medication or dosage without advance approval from any provider. I will provide my medication for pill counts at the provider’s request. I will not request early refills. 3. I will keep regular appointments with my provider. 4. I will inform my provider within one business day if I am hospitalized for any reason, or if I have another condition that requires the prescription of a controlled drug (like narcotics, tranquilizers, barbiturates, or stimulants). 5. I will choose one pharmacy where all my prescriptions will be filled. 6. I understand that lost or stolen prescriptions will not be replaced, so I will keep my prescription and medication in a safe place or lock box. 7. I agree to avoid all illegal and recreational drugs (including alcohol) and will provide urine or blood specimens at the doctor’s request to monitor my compliance. 8. I agree to follow my doctor’s recommendations regarding the operation of motor vehicles or heavy machinery while taking this medication. 9. Refills will be made only during regular office hours, which are Monday-Friday from 8 am to 5 pm. Refills will not be made at night, on weekends or during holidays. I am responsible for keeping track of my remaining medication, so that I can call for refills in advance. This way, I will not run out of medication. I affirm and agree to the provisions of this agreementPharmacy Name(Required) Please provide the name of the pharmacy where all your prescriptions will be filled.Pharmacy Phone(Required) Pharmacy Fax(Required) Pharmacy Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient Name(Required)By entering my name here, I affirm and agree to the conditions of treatment as outlined above. First Last Date of Birth(Required) Date(Required) CommentsThis field is for validation purposes and should be left unchanged. Δ
