Treatment Agreement

At Your Infinity Health, we strive to provide all patients with safe, effective and compassionate care. In order to do so, we need your cooperation and agreement as follows:

I agree to be on time for my appointments, and not miss any without prior arrangement. I understand I may not get a prescription without appointment, and that this may lead to withdrawal symptoms and/or relapse.

I agree to notify clinic staff PRIOR to my appointment if I am not able to keep the appointment for any legitimate reason, such as an emergency. I understand the decision to provide a prescription refill without an appointment — even in the case of an emergency situation — is entirely at the discretion of my provider.

I agree to safeguard my prescription medications against loss and theft at all times. I understand that lost or stolen medications WILL NOT be refilled until the next prescription is due.

I agree to take all prescribed medications exactly as instructed to do so, and not take more than the prescribed amount. I understand that if I run out of medication early because I took more than the prescribed amount, I may not be provided additional medication until the next refill is due; and that this may lead to withdrawal symptoms and/or relapse.

I agree that if I end up with extra medication for any reason (such as taking LESS than the prescribed amount), I will disclose this to my provider at the next appointment so that the subsequent prescription(s) can be adjusted. I understand that I must not keep extra medication in my possession for any reason.

I understand that any of the following may be IMMEDIATE GROUNDS FOR DISMISSAL FROM THE PROGRAM WITHOUT ANY FURTHER PRESCRIPTIONS OR TREATMENT:Violent, threatening or hostile behavior towards providers or other staff.

Any diversion or attempts to divert medications in the form of selling or sharing with others.

Frequent or excessive missed appointments.

With my signature below, I acknowledge that I have read and understood these policies and agree to abide by them at all times. I understand that violation of ANY part of this agreement may be grounds for dismissal from treatment at Your Infinity Health