physiciansform1


 

 

EMERGENCY TREATMENT REQUEST

 

Below is the information you will need to assist you in treating my patient:

 

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First/ Last

 

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Condition(s)

 

 

As you are aware, some chronic pain conditions are such that extremely painful conditions can arise where
the required treatment of medication is more than the patient currently has on hand.

My patient is not a substance abuser but may need narcotic medications to treat this episode he/she is
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:

______________________________________________________________________________

 

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It is often difficult for Pain Patients to receive proper care because of substance abusers
who go in looking to obtain narcotics for a ‘high’. I can assure you that such is not the case
with this patient.

Please feel free to call me with any questions regarding this patient's care.

 

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Signature Date

 

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Address Office Phone

          

 

 

 

 

 

 

 

 

 

 

 

This form provided by Our Chronic Pain Mission http://cpmission.com/

© 2002 OCPM