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    Sample Patient Contract

    Uploaded by

    Imc Ayurved
    This document outlines a patient contract between a patient and Dr. Gaurav Dwivedi for natural health care treatment using Panchgavya medicines. The contract specifies that (1) the medication may reduce but not eliminate the disease and improve quality of life, (2) risks of dependence and side effects are understood, and (3) responsibilities include following dosage instructions, attending follow-ups, and not misusing or sharing the medication.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Sample Patient Contract

    Uploaded by

    Imc Ayurved
    79 views3 pages
    This document outlines a patient contract between a patient and Dr. Gaurav Dwivedi for natural health care treatment using Panchgavya medicines. The contract specifies that (1) the medication may reduce but not eliminate the disease and improve quality of life, (2) risks of dependence and side effects are understood, and (3) responsibilities include following dosage instructions, attending follow-ups, and not misusing or sharing the medication.

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    Sample Patient Contract

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    This document outlines a patient contract between a patient and Dr. Gaurav Dwivedi for natural health care treatment using Panchgavya medicines. The contract specifies that (1) the medication may reduce but not eliminate the disease and improve quality of life, (2) risks of dependence and side effects are understood, and (3) responsibilities include following dosage instructions, attending follow-ups, and not misusing or sharing the medication.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    79 views3 pages

    Sample Patient Contract

    Uploaded by

    Imc Ayurved
    This document outlines a patient contract between a patient and Dr. Gaurav Dwivedi for natural health care treatment using Panchgavya medicines. The contract specifies that (1) the medication may reduce but not eliminate the disease and improve quality of life, (2) risks of dependence and side effects are understood, and (3) responsibilities include following dosage instructions, attending follow-ups, and not misusing or sharing the medication.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    NATURAL HEALTH CARE CENTER

    Sample Patient Contract

    This is an agreement between _____________________________________________________ (the patient) and

    Medical practiceowner Dr.Gaurav Dwivedi M.D (Panchgavya) concerning the use of my medicins for
    the treatment of ………………..

    The medication will probably not completely eliminate my deasease, but is expected to reduce it enough
    that I may become more functional and improve my quality of life.

    1. I understand that opioid analgesics are strong medications for………………………………. and have
    been informed of the risks and side effects involved with taking them.

    2. In particular, I understand that my decease could cause physical dependence. If I suddenly stop
    or decease the medication,then precticeowner will not me liable.

    3. I understand it is my responsibility to inform the doctor of any and all side effects I have from
    this medication.

    4. I agree to take this medication as prescribed and not to change the amount or frequency of the
    medication without discussing it with the prescribing practiceowner. Running out early,
    needing early refills, escalating doses without permission, and losing prescriptions may be
    signs of misuse of the medication and may be reasons for the practiceowner to
    discontinue prescribing to me.

    5. I agree to keep my medication in a safe and secure place. Lost, stolen, or damaged medication
    will not be replaced.

    6. I agree not to sell, lend, or in any way give my medication to any other person.
    7. I agree not to drink alcohol or take other mood-altering drugs while I am taking opioid analgesic
    medication. I agree to submit a urine specimen at any time that my doctor requests and give
    my permission for it to be tested for alcohol and drugs.
    8. I agree that I will attend all required follow-up visits with the doctor to monitor this
    medication and I understand that failure to do so will result in discontinuation of this treatment.
    9. I understand that this procedure of treatment is an alternative method of arurvedic treatment, so,
    before using the prescribed medicine I will be make sure about the method of treatment and its
    condition.

    I have read the above, asked questions, and understand the agreement. I am hereby allowing the practice owner
    to start treatment.

    Patient signature

    Doctor signature

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