New Patient Registration Form
Already Registered? Login Here to Edit or Complete Form

Today's Date: 2/22/2012		* Required Fields
Email: *    Select Your Password: *
Patient's First Name:		Middle Name:			Last Name:
D.O.B.: 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Street Address:	Apt#
City:		State:			Zip Code:
Home Phone #:		Work Phone #
Social Security#:		Driver's License#:			State:
Sex:	Female       Male	Marital Status:		Single     Married     Divorced   Widowed SO
Spouse's Name:		Spouse's Work #:
Your Employer:
Employer's Address:
City:		State			Zip Code:
Employer's Phone #:		Position:
Next of Kin:		Relationship:
Home Phone #:		Work Phone #:
Person to Notify in Emergency:		Relationship:
Home Phone #:		Work Phone #:
Responsible Party's Name:
Relationship to Patient:		Home Phone #:
Referred By:
Physician's Address:
Physician's Phone #:
Reason for Appointment:
May we leave a message on your answering machine?				Yes       No

Interventionr-Pain Physicians Of South Florida

Nancy Erickson, D.O.

Interventionr-Pain Physicians Of South Florida

Nancy Erickson, D.O.

Interventionr-Pain Physicians Of South Florida

Nancy Erickson, D.O.

Interventionr-Pain Physicians Of South Florida

Nancy Erickson, D.O.

Interventionr-Pain Physicians Of South Florida

Nancy Erickson, D.O.

PAIN MANAGEMENT AGREEMENT

Our goal in the field of Pain Management Medicine is to assist patients' with the treatment of their
chronic pain. We achieve this goal through various modalities, including injections or nerve blocks,
physical therapy, exercise programs, psychological counseling when needed, and referrals to surgeons or
other specialists as required. We strive to manage pain through·means other than medications to allow
patients to live a relatively pain free life. We seek to treat the cause of the pain and not the symptoms.
However, we also understand that strong narcotic analgesic and other prescription medications may
be indicated for the treatment of certain chronic pain conditions.

The purpose of this Agreement is to clarify the conditions under which Dr. Nancy Erickson will prescribe
medications for you. This agreement will help you and Dr. Nancy Erickson comply with the laws
regarding controlled pharmaceuticals and prevent misunderstandings about the medicines you may take
for your pain condition. Please read each and every item in this agreement very carefully.

I UNDERSTAND AND AGREE TO THE FOLLOWING TERMS OF ANY AND ALL PRESCRIPTIONS:

1. I WILL USE MY MEDICATION(S) AT A RATE NO GREATER THAN THAT PRESCRIBED
   BY DR. NANCY ERICKSON. IFI DO OVER-USE MY MEDICATION, THAT
   MEDICATION WILL NOT BE REFILLED EARLY, AND I MAY BE WITHOUT PAIN
   MEDICATION FOR SOME PERIOD OF TIME.
   
   
2. I WILL NOT SHARE, SELL OR TRADE MY MEDICATION WITH ANYONE. I WILL NOT
   ATTEMPT TO OBTAIN ANY CONTROLLED MEDICINCES, INCLUDING OPIOID PAIN
   MEDICINES, CONTROLLED STIMULANTS, OR ANTI-ANXIETY MEDICINES FROM
   ANY OTHER DOCTOR. I WILL SAFEGUARD MY WRITEN PRESCRIPTIONS AND
   PAIN MEDICINE FROM LOSS OR THEFT. I UNDERSTAND THAT LOST OR STOLEN
   WRITTEN PRESCRIPTIONS OR MEDICINES WILL NOT BE REPLACED.
   
   
3. SUDDEN DISCONTINUATION OF A NARCOTIC PAIN MEDICATION MAY LEAD TO
   UNPLEASANT OR DANGEROUS WITHDRAWL SYMPTOMS.
   
   
4. THE POTENTIAL RISKS AND SIDE EFFECTS OF MEDICATIONS TAKEN FOR PAIN,
   EITHER SHORT TERM OR LONG TERM, CAN INCLUDE: DROWSINESS, NAUSEA,
   CONSTIPATION, ITCHING, DIFFICULTY WITH URINATION, TOLERANCE,
   DEPENDANCE, ADDICTION, AND OVERDOSE.
   
   
5. IN THE EVENT THAT DR. NANCY ERICKSON FEELS THAT YOUR DOSE OF PAIN
   MEDICATION IS EXCESSIVE OR MAKES THE DIAGNOSIS OF ADDICTION OR
   OVERDOSE, DR. NANCY ERICKSON WILL REDUCE THE MEDICINE OVER A PERIOD
   OF TIME (DAYS, WEEKS, AND MONTHS) AS NECESSARY TO AVOID WITHDRAWL
   SYMPTOMS. ALSO, A DRUG-DEPENDENCE TREATMENT OR DETOXIFICATION
   PROGRAM MAY BE RECOMMENDED.
   

Interventionr-Pain Physicians Of South Florida

Nancy Erickson, D.O.

6. I UNDERSTAND AND AGREE THAT I AM NOT TO RECEIVE ANY TYPE OF
   PRESCRIPTION PAIN MEDICATION OR SEDATIVE MEDICATION FROM ANY
   PHYSICIAN OTHER THAN DR. NANCY ERICKSON UNLESS THERE IS A SPECIFIC
   MEDICAL NECESSITY. SHOULD YOUR CAREGIVER OR YOU RECEIVE ANY PAIN OR
   SEDATIVE MEDICATIONS FROM ANY OTHER PHYSICIAN, YOUR CAREGIVER OR
   YOU MUST INFORM DR. NANCY ERICKSON'S OFFICE EITHER BY TELEPHONE OR IN
   WRITING WITHIN 72 HOURS OF HAVING FILLED THE PRESCRIPTIONS.
   
   
7. REFILLS OF YOUR PRESCRIPTIONS WILL BE ISSUED ONLY AT THE TIME OF AN
   OFFICE VISIT, DURING REGULAR OFFICE HOURS, OR IMMEDIATELY FOLLOWING A
   PROCEDURE.
   
   
8. REFILLS WILL NOT BE AVAILABLE DURING EVENINGS, ON WEEKENDS OR
   HOLIDAYS, AND WITHOUT AT LEAST 72 HOURS NOTICE TO DR. NANCY
   ERICKSON'S OR HER OFFICE STAFF.
   
   
9. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO KEEP TRACK OF MY SUPPLY OF
   PAIN MEDICATION AND TO MAKE TIMELY APPOINTMENTS WITH DR. NANCY
   ERICKSON TO HAVE YOUR PRESCRIPTION(S) REFILLED. LAST-MINUTE REQUESTS
   FOR PRESCRIPTION REFILLS ARE NOT WELCOME.
   
   
10. DR. NANCY ERICKSON MAY, AT HER DISCRETION, ISSUE A CHANGE OF YOUR
    MEDICATION(S) BASED ON A TELEPHONE CONVERSATION THAT SHE HAS HAD
    REGARDING YOUR PAIN CONDITION AND THE EFFECTS THEY MAY HAVE ON THIS
    CONDITION.
    
    
11. I WILL COMMUNICATE FULLY AND TRUTHFULLY WITH DR. NANCY ERICKSON
    ABOUT THE CHARACTER AND INTENSITY,OF MY PAIN,THE EFFECT OF THE PAIN
    ON MY DAILY LIFE, AND HOW WELL THE MEDICINE IS HELPING TO RELIEVE THE
    PAIN. I UNDERSTAND THAT I, OR MY CAREGIVER IS RESPONSIBLE FOR
    INFORMING DR. NANCY ERICKSON EITHER IN PERSON, AT THE FOLLOW-UP, OR BY
    TELEPHONE AT DR. NANCY ERICKSON'S OFFICE AT (954-433-8711) DURING
    REGULAR BUSINESS HOURS (7:00 A.M.- 3:30 P.M., MONDAY THROUGH THURSDAY,
    FRIDAY 7:00 A.M. - 3:00 P.M.) REGARDING ANY PROBLEMS OR SIDE EFFECTS
    ENCOUNTERED WITH THE MEDICATION. A MESSAGE MAY ALSO BE LEFT FOR DR.
    NANCY ERICKSON AT (954-433-8711) REGARDING ANY OF THESE PROBLEMS.

Interventionr-Pain Physicians Of South Florida

Nancy Erickson, D.O.

12. I HAVE BEEN ADVISED TO ABSTAIN FROM OR SIGNIFICANTLY MODERATE MY USE
    OF ALCHOLIC BEVERAGES WHILE TAKING MED1CATION FOR MY PAIN
    CONDITION. I WILL NOT USE ANY ILLEGAL CONTROLLED SUBSTANCES,
    INLUDING MARIJUANA, COCAINE, HEROIN,ECSTASY, GHB, ETC. IF I AM A
    CIGARETTE SMOKER, I UNDERSTAND THAT I WILL BE ASKED TO QUIT.
    CIGARETTE SMOKERS TYPICALLY HAVE A DECREASED RESPONSE TO PAIN
    TREATMENT BECAUSE OF THE EFFECTS OF SMOKING ON OXYGEN DELIVERY TO
    THE PERIPHERAL TISSUES. ADDITIONALLY, OBESITY IS ONE OF THE MOST
    IMPORTANT CAUSES OF FAILED TREATMENT FOR CHRONIC PAIN. EVERY TEN
    POUNDS OF EXCESS WEIGHT THAT ONE CARRIES ON HIS/HER BODY RESULTS IN
    ONE HUNDRED POUNDS OF INCRESASED PRESSURE ON THE SPINE, VERTEBRAL
    DISCS, AND SPINAL NERVES. EXCESSIVE WEIGHT WILL THEREFORE RESULT IN AN
    INCREASE IN PAIN.· IF YOU ARE OVERWEIGHT YOU WILL NEED TO ENROLL IN AN
    WEIGHT LOSS PROGRAM. PHYSICAL THERAPY WILL ALSO BE DIRECTED IN THIS
    AREA AS WELL.
    
    
13. IF PHYSICAL THERAPY IS PRESCRIBED, I AGREE TO ATTEND AND PARTICIPATE TO
    THE FULLEST EXTENT POSSIBLE. IF THERE ARE ANY PROBLEMS WITH MY
    PHYSICAL THERAPY, I AGREE TO COMMUNICATE THIS TO DR. NANCY ERICKSON
    SO THAT SHE CAN MAKE THE APPROPRIATE CHANGES IN MY THERAPY PROGRAM.
    
    
14. I AGREE THAT I WILL SUBMIT TO A BLOOD OR URINE TEST IF REQUESTED BY DR.
    NANCY ERICKSON TO DETERMINE MY COMPLIANCE WITH MY REGIMEN OF PAIN
    MEDICATION. FUTHERMORE, AT DR. NANCY ERICKSON'S DISCRETION, THE
    PRIMARY CAREGIVER WHO'S SIGNATURE APPEARS BELOW SHALL ALSO BE
    SUBJECT TO PERIODIC URINE AND/OR BLOOD TESTING.
    
    
15. IF REQUESTED, I WILL BRING ALL UNUSED PAIN MEDICINE TO AN OFFICE VISIT
    FOR A "PILL COUNT". DR. NANCY ERICKSON MAY REQUEST ADDITIONAL "PILL
    COUNTS" AT ANY TIME, AND I AGREE TO COMPLY WITH THESE REQUESTS. I
    AGREE THAT MY CAREGIVER OR I WILL BRING THE MOST RECENT PRESCRIPTION
    CONTAINER FOR EACH MEDICATION TO EACH VISIT WITH MY PHYSICIAN. THESE
    CONTAINERS MUST CORRESPOND TO THEIR LAST PRESCRIPTION RECORDED IN
    THE MEDICAL RECORD WITH THE PRESCRIPTION LABELS !NTACT AND LEGIBLE
    SO THAT DR. NANCY ERICKSON OR STAFF MEMBER MAY DOCUMENT
    APPROPRIATE CONTROL INFORMATION. SPECIFICALLY, THE PRESCRIPTION
    REGISTRATION NUMBER AND PHARMACY TELEPHONE NUMBER WILL BE NOTED
    AND VERIFIED.
    

Interventionr-Pain Physicians Of South Florida

Nancy Erickson, D.O.

16. I WILL USE ONLY ONE PHARMACY TO FILL PRESCRIPTIONS FOR YOUR PAIN
    MEDICATIONS.
    
    MY PHARMACY IS (NAME)
    
    PHONE:
    
    PHARMACY LOCATION (STREET/CITY):
    
    
    I AUTHORIZE DR. NANCY ERICKSON AND MY
    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 MEDICATION. I AUTHORIZE DR. NANCY ERICKSON TO PROVIDE ME A COPY
    OF THIS AGREEMENT TO MY PHARMACY. I AGREE TO WAIVE ANY APPLICABLE
    PRIVILEGE OR RIGHTS OF PRIVACY OR CONFIDENTIALITY WITH RESPECT TO
    THESE AUTHORIZATIONS. I FURTHER CONCENT TO DR. NANCY ERICKSON
    CONTACTING OTHER PHYSICIANS TO DISCUSS PRIOR PRESCRIPTIONS THAT I
    HAVB RECEIVED FROM THOSE PHYSICIANS OR TO OBTAIN THE RESULTS OF
    DIAGNOSTIC TESTING (PAST OR PRESENT) IN ORDER TO OBTAIN ADEQUATE
    INFORMATION ABOUT MY CONDITION.
    
    
17. I FURTHER UNDERSTAND THAT THIS AGREEMENT IS ESSENTIAL TO THE TRUST
    AND CONFIDENCE NECESSARY IN A DOCTOR-PATIENT RELATIONSHIP AND THAT
    DR. NANCY ERICKSON UNDERTAKES TO TREAT YOU BASED ON THIS AGREEMENT.
    I UNDERSTAND THAT IF I BREAK THIS AGREEMENT OR PROVIDE ANY FALSE
    INFORMATION, DR. NANCY ERICKSON WILL STOP PRESCRIBING THESE PAINCONTOL
    MEDICINES AND YOU MAY BE IMMEDIATELY REMOVED FROM DR.
    NANCY ERICKSON'S CARE.
    

I have reviewed all of the items contained in this four (4) page agreement. I agree to follow all of the
guidelines that are described above. All of my questions and concerns regarding treatment have
been adequately answered. A copy of this document will be given to me upon request. I voluntarily
consent to participation in the pain medication program described in this Agreement.