Resource Center: form
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Description:
A referral form which includes both doctor and patient information.
Source:
Clinical Tools, Inc.
Description:
Initial Patient Contact about Buprenorphine Checklist
Source:
AAAP.org
Description:
Buprenorphine Treatment Agreement - handout for patients.
Source:
AAAP.org
Description:
A patient handout that explains opioid dependence to the abuser.
Source:
Reckitt Benckiser
Description:
Sample of a patient information and consent to treatment with buprenorphine.
Source:
CSAM
Description:
This form is filled out by the patient. It authorizes the physician and members of his or her staff to call prior to an appointment to remind the patient of appointment dates and times.
Source:
Adapted from Reckitt Benckiser Buprenorphine form
Description:
This is an authorization form from the patient to the physician indicating the type of information that can be released or received (e.g., medical history, treatment information, records, etc.).
Source:
Adapted from Reckitt Benckiser Buprenorphine form
Description:
This form provides an example of the wording and structure of a consent for release of information form.
Source:
AAAP Pedigree Form - Medical Family History
Description:
A blank pedigree form to help observe a family history being taken for a typical patient that you may encounter in any primary care setting. Includes a general template with standard pedigree symbols, red flags, and useful reminders. This blank pedigree form is used to observe a family history for a patient:
An example of a stop-smoking agreement form
Description:
An example a stop-smoking agreement form. QUIT FOR GOOD RX
I agree to stop smoking on:
Date: _____/_____/______.
I understand that stopping smoking is the single best thing I can do for my health, and my
