TriValley Primary Care in an effort to manage chronic conditions more effectively is enacting a Controlled Substances Management Agreement between doctor and patient on new and long term prescriptions classified as controlled substances. Please read it carefully. Failure to adhere to the terms of the agreement include dismissal from the practice.

Please use the Type and Tab feature described below to complete the form, but DO NOT SIGN THE FORM UNTIL YOU HAVE DISCUSSED THIS WITH YOUR PHYSICIAN.

Type and Tab: This agreement is designed to be completed on your computer using Adobe Reader.* Click on the agreement to open it, then start by clicking your mouse pointer on the first field. You may use the Tab key to move to the next field to be entered. Please review the information you entered, and print it by clicking on the Print Form button at the bottom of the agreement. Please hand the agreement to the receptionist as you arrive. Do NOT sign the agreement until your appointment.

* Note: Or, you may simply print the agreement by clicking on the Print Form button at the bottom and complete it with a pen. Please print legibly.

Controlled Substances Management Agreement

If you do not have Adobe Reader installed, click here to get the latest version.