Opioid Waiver Form in Farmington Hills Opioid Waiver Name * Name First First Last Last Patient's Name * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Date of Birth * Email * Name of Controlled Substance containing an Opioid * Dosage * Quantity Prescribed * Number of Refills * A controlled substance is a drug or other substance that the United States Drug Enforcement Administration has identified as having a potential for abuse. My provider shared the following: The risks of substance use disorder and overdose associated with the controlled substance containing an opioid. Individuals with mental illness and substance use disorders may have an increased risk of addiction to a controlled substance. (Required only for minors.) Mixing opioids with benzodiazepines, alcohol, muscle relaxers, or any other drug that may depress the central nervous system can cause serious health risks, including death or disability. (Required only for minors.) For a female who is pregnant or is of reproductive age, the heightened risk of short and long-term effects of opioids, including but not limited to neonatal abstinence syndrome. Any other information necessary for patients to use the drug safely and effectvely as found in the patient counselling information section of the labeling for the controlled substance. Safe disposal of opioids has shown to reduce injury and death in family members. Proper disposal of expired, unused, or unwanted controlled substances may be done through community take-back programs, local pharmacies, or local law enforcement agencies. Information on where to return your prescription drugs can be found at http://www.michigan.gov/deqdrugdisposal. It is a felony to illegally deliver, distribute, or share a controlled substance without a prescription properly issued by a licensed health care provider. According to Michigan State Law any controlled substance prescribed to an animal must first have its owner checked through the Michigan Automated Prescription System which shows any controlled substance prescribed to him. This must be run every 90 days upon issuance of a prescription, and I hereby give Jeffrey Animal Hospital the authority to do so. I acknowledge the potential benefits and risks of an opioid medication as described by my provider along with the responsibility of properly managing my medication as stated above. Printed Name of Parent/Guardian; Patient's Representative or other authorized adult. * Date * Michigan State Law Prescription Changes Due to recent changes in Michigan State Law, effective June 1st 2018 any controlled substances issued to an animal must first have the owner's name checked through State website checking the prior 2 years for controlled substances issued to said person. This is due to opiate abuse recently being brought to attention in the news and internet. For Jeffrey Animal Hospital to sell/dispense any controlled substances, we need the owner to give us verbal approval to check this State website in your name. Only this person can pick up the prescription at Jeffrey Animal Hospital at the same time signing a written consent and opioid abuse information sheet and showing their valid driver's license. The owner coming in must be 18 years or older. We can issue a written prescription instead for you to fill at a local pharmacy. Please allow at least 2 hours for any prescription refills. Thank you and we apologize for any inconvenience. Captcha Submit If you are human, leave this field blank.
