Neurosurgical & Spinal Surgery Associates, P.C.

The Spine Center at Rapid City w Neurology Associates w Electrodiagnostic Services

Promotion Rehabilitation Center w Practice Management Services

4141 Fifth Street, Rapid City, SD 57701 w 605-341-2424 w Fax 605-341-4547

PATIENT INFORMATION REGARDING PAIN MEDICATION

Please read the following notice carefully and if you have any questions or concerns, contact our staff for assistance.

We ask our patients to make arrangements to obtain prescriptions or prescription refills prior to the weekend. You must call in your prescription request by 5pm on Thursday. We will not provide prescriptions or prescription refills after 5pm on Thursday through 8am on Monday.

Please call or request your prescription refill at least 48 hours prior to your last dose. This will assure the most prompt response to your request. Do not wait until the day your medication(s) run out. Our clinical staff needs sufficient time to review your request for refill and to process it properly.

Some prescriptions cannot be refilled by phone. Please use only one pharmacy for refills of your pain medication. Using the same pharmacy helps assure that the pharmacy will stock your medication for refills and that the pharmacy will know that you have a legitimate need for pain medication.

You are personally responsible for the safekeeping of your medication! Please do not sell, trade or give it away. If your medication is damaged, stolen, or lost please notify us right away.

Please do not seek pain medication from any other doctor unless approved by our clinical staff. Let us know if at any time another doctor prescribes medication for you.

You are welcome to contact us any other day of the week or you may visit with our staff during your appointment regarding your prescription or refill.

This restriction will apply to the following drug types:

1.                  Narcotics. (Examples include, Vicodin, Percocet, Oxycontin and Codeine)

2.                  Non-Steroidal Anti-Inflammatory drugs, “NSAIDS”. (Examples include; Motrin, Vioxx, Celebrex and Naprosyn).

3.                  Non-narcotic and Other Pain Medicine. (Examples are; Ultram or Darvocet).

4.                  Muscle Relaxants. (Examples are; Flexeril or Soma)

Again, if you have questions about this notice please contact one of our medical staff at (605) 341-2424.

I acknowledge that I have read, understand and been given a copy of Neurosurgical & Spinal Surgery Associates, P.C.’s policy on prescription pain medication.

Patient/ Patient’s Representative Signature                                             Date

(3/26/07)

(©8/2007)

(© 8/24/07)