Sample Client/Pharmacist Agreement Form

Welcome to our pharmacy. We look forward to assisting you with your program and any other health requirements that may arise. We are committed to providing a comprehensive professional service to our clients, which includes advice on medication and health matters.

Your program is a partnership between yourself, your doctor and our pharmacists.

The section overleaf briefly outlines the main points of our program and is designed to be informative and to clarify any issues or queries you may have.

We uphold the principles of the Consumer rights charter as outlined below.

Consumer rights charter

This Charter is designed to provide guidance to both consumers and service providers in ensuring a relationship of mutual respect and consideration. Furthermore, it is designed to aid conflict resolution to the mutual benefit of both consumers and service providers. While the rights detailed below are for the benefit of the consumers, they should also treat their providers and other program participants with consideration and respect.

The following is a statement of rights that all consumers participating in a program to receive methadone, buprenorphine or other pharmacotherapy, can expect from their pharmacist providers.

·  Quality pharmacy service.

·  Considerate care that respects privacy and dignity.

·  Adequate information on appropriate aspects of service provided or treatments available, in terms that can be understood.

·  Non-judgmental treatment that is unassuming and non-discriminatory and is fair and equitable.

·  Information about the treatment and participation in decision making which relates to their program and their general health.

·  Access to information from their pharmaceutical records, unless specifically directed otherwise by their prescribing doctor and accurate and honest responses to questions relating to their treatment.

·  Discreet and confidential service and confidential handling of their pharmaceutical records.

·  The right to consent to, or refuse treatment.

·  The right to make a complaint and receive a fair hearing and to have their concerns heard without fear of repercussions.

·  Where the pharmacy supplies clean injecting equipment, the right to obtain this equipment, without this having any influence on their program.

If the consumer feels that they have been treated in a way that is contrary to these conditions, they can lodge a complaint to the health services commissioner or the pharmacy board in that state or territory.

This Sample Client/Pharmacist Agreement Form has been provided as part of the Pharmaceutical Society of Australia’s Guidelines for pharmacists providing opioid pharmacotherapy services (July 2004). Pharmacists should refer to the full guidelines for further information. The Society takes no responsibility in the use and adaptation of this form by pharmacists.


Supervised dosing

·  Your program involves dosing of a medicine under the supervision of our pharmacist.

·  Your dose will not be supplied if you appear to be intoxicated. This is to ensure your safety and we have a responsibility to ensure this is maintained.

·  Particulars of your program will be discussed with your doctor as part of the normal conversations we have in our doctor/pharmacist relationship and in line with our professional duty of care.

·  If any difficulties or problems arise in relation to your program, you should feel welcome to discuss them with us.

·  Pharmacies operate in line with state and commonwealth privacy legislation. Please let our pharmacists know of any specific circumstances that may concern you.

·  It is important for anyone prescribing (eg. doctors, dentists) or supplying (eg. other pharmacists) your medicines to know that you are receiving this treatment because of possible drug interactions, side-effects or overdose. It is safer that all your medicines be managed at one pharmacy.

Hours of supply

·  Your doses will be available:
……………………………………………………

·  Regular attendance is the single most important factor for a successful program. You will do better if you do not miss doses. Future access to take-away doses may also depend on your attendance.

Payment

·  The cost is $……………… per week / day and is payable in advance. Your payment terms are as follows:
……………………………………………………
(insert payment frequency, method of payment etc.)


Prescriptions and doses

·  We cannot dose you without a valid prescription. It is your responsibility to obtain new prescriptions when they are due. Please ask if you are not sure when your prescription expires.

·  Our pharmacists can only adjust your dose in accordance with the written directions on your prescription. Any alterations to your dose need to be determined between yourself and your doctor. We are happy to provide input to those considerations.

Take-away doses

·  Take-away doses are only supplied in line with state health department protocols and if your doctor has prescribed it for you. It is your responsibility to ask your doctor to authorise any variations.

·  Any extra or unusual take-away doses should be arranged as early as possible as they may require health department approval.

·  Take-away doses can be lethal to children and non-dependent people. All take-away doses should be stored in a safe place away from other people’s access.

·  Take-away doses cannot be replaced for any reason whatsoever. Losing your take-away doses may affect your obtaining them in the future.

Missed doses

·  We will inform your doctor if you miss
……..…………. or more consecutive doses
(number in words)
of your treatment. No further doses can be provided without the doctor’s authorisation.

Warnings

·  Some treatments can affect your capacity to drive motor vehicles, operate machinery and participate in dangerous sport. You should consider this in deciding whether to perform these activities.

·  Combining alcohol and/or sedatives with your treatment, can affect these skills at any time. Using heroin, other opiates, or any sedatives (such as benzodiazepines) while on this program can be dangerous.

This Sample Client/Pharmacist Agreement Form has been provided as part of the Pharmaceutical Society of Australia’s Guidelines for pharmacists providing opioid pharmacotherapy services (July 2004). Pharmacists should refer to the full guidelines for further information. The Society takes no responsibility in the use and adaptation of this form by pharmacists.

We ask that you join us in signing this agreement.

Client / Pharmacist
Print name…………………………………………….. / Print name……………………………………………..
Signature……………………………………………… / Signature………………………………………………
Date………………………………………………….. / Date…………………………………………………..

This Sample Client/Pharmacist Agreement Form has been provided as part of the Pharmaceutical Society of Australia’s Guidelines for pharmacists providing opioid pharmacotherapy services (July 2004). Pharmacists should refer to the full guidelines for further information. The Society takes no responsibility in the use and adaptation of this form by pharmacists.