EMERGENCY TREATMENT REQUEST
Below is the information you
will need to assist you in treating my patient:
___________________________________________________________
First/ Last
__________________________________
Condition(s)
As you are aware, some
chronic pain conditions are such that extremely painful conditions can arise
where My patient is not a substance abuser but may need
narcotic medications to treat this episode he/she is
the required treatment of medication is more than the patient currently
has on hand.
currently
experiencing.
Patient Information
Diagnosis:
____________________________________
Current preventive medication(s):
__________________________________________________
______________________________________________________________________________
Current abortive and/or pain
medication(s): ___________________________________________
______________________________________________________________________________
Medications known to be
effective for this patient in an emergency situation:
______________________________________________________________________________
______________________________________________________________________________
It is often difficult for Pain Patients to receive proper care
because of substance abusers Please feel free to call me with any
questions regarding this patient's care.
who go in
looking to obtain narcotics for a �high�. I can assure you that such
is not the case
with this patient.
______________________________________________________________________________
Signature Date
______________________________________________________________________________
Address
Office Phone
This form
provided by Our Chronic Pain Mission http://cpmission.com/
� 2002 OCPM