• I agree to enter into a treatment contract with Sage Neuroscience Center to provide me with healthcare services to include prescribing controlled substances as detailed below. Controlled substances carry a higher risk for medical complications, abuse, dependence, and diversion. To ensure safety, these medications should be used at the lowest necessary dose and not in combination with other controlled substances, alcohol, and cannabis without discussing with my provider.
  • Name of Pharmacy
  • Pharmacy address or cross streets.

  • This agreement will remain in effect for one year from the date signed below.

  • MM slash DD slash YYYY