PATIENT AGREEMENT FOR

TAKE-HOME MEDICATION
PATIENT ID: DATE:
FIRST NAME: CLINIC:
LAST NAME:
PRESCRIBER:
VISIT TYPE: TELEMEDICINE IN-PERSON
MEDS PROVIDED: DAYS

The following is a list of the requirements for obtaining take-home medication.

If form is being completed by client in-person: Please read each item below and check the box to confirm that
you understand and agree to abide by the requirement then proceed to the next page.

If form is being completed by client via telemedicine: Read each item to the client and check the box once they
have given their verbal agreement. Proceed to the next page.
AGREE?
1. I will take the medication exactly as prescribed by my doctor.
2. I will have Naloxone (Narcan) near my take-home medication and discuss with my
counselor how to inform people in my residence how and when to use it.
3. I understand that it is illegal to share, sell, or in any other way divert my medication
to anyone else. I will not do this.
4. I will keep the medication in a safe and secure location in an approved lock box (if
one is available) and ensure that no one will have access to the box, or the
medication contained within.
5. I will discuss my plan to keep the take-home medication safe and secure with my
counselor prior to taking it home.
6. I understand that people have died by mixing buprenorphine or methadone with
other drugs like alcohol and benzodiazepines (drugs like Valium®, Klonopin® and
Xanax®).
7. I will not take non-prescribed opioids or benzodiazepines, alcohol, or illicit drugs
during treatment.
8. I will attend all scheduled appointments, including telehealth, to continue working
on my recovery.
9. I will participate in video calls when requested to show the contents of my lock box
and the medication contained within.
10. I understand that during this period I will work with staff and my support system to
continue working on my recovery.
11. I agree that in order to keep myself, my family, and others safe from infection of
COVID-19, taking home my medication is a safe alternative to daily dosing.
GO TO NEXT PAGE è

Revised 3/28/2020 Page 1 of 2

 PATIENT AGREEMENT FOR
TAKE-HOME MEDICATION

IN-PERSON CLIENT AGREEMENT

I understand, and agree to, the requirements for receiving take-home medications. I agree to abide by these
requirements. I understand that failure to follow these requirements will result in loss of my take-home
medication privilege.*

PRINT NAME

SIGNATURE

TELEMEDICINE CLIENT AGREEMENT

READ THE FOLLOWING TO THE CLIENT:

I’m going to read you a short statement and ask for your verbal agreement which will have the same effect as if
you were signing this form.

I understand, and agree to, the requirements for receiving take-home medications. I agree to abide by these
requirements. I understand that failure to follow these requirements will result in loss of my take-home
medication privilege. Should you have to return to daily dosing, this facility will be following the guidance
provided by the Centers for Disease Control (CDC) and Delaware’s Division of Public Health in regard to screening
all clients and staff and enforcing social distancing.

Do you agree with the statement I have just read?

AGREEMENT VERBALLY CONFIRMED BY CLIENT

STAFF INITIALS

*
Please note that should you have to return to daily dosing, this facility will be following the guidance provided by the
Centers for Disease Control (CDC) and Delaware’s Division of Public Health in regard to screening all clients and staff and
enforcing social distancing.
Revised 3/28/2020 Page 2 of 2