Controlled Medication Protocol Form – Small Animal Clinic At Piedmont Equine

Your pet has been prescribed a controlled drug. Please review and sign.

In accordance to US DEA Drug Control Act regarding opioid medications:
• For acute pain or condition, the dose shall not exceed a 7-day supply. If after 7 days additional medications are still needed for the condition or control of pain, the patient must be seen and reevaluated.
• For chronic pain or condition that requires treatment beyond 7 days, the patient must be seen and re-evaluated at least every six months.
• Due to the risk of drug abuse, opioid medications are prescribed only in the case that other medications are ineffective.
• Pet owners are responsible for securing opioid medications once prescribed. Do not allow access to medications to minors or vulnerable persons.
• Pet owners are responsible for proper disposal of any unused drug.
o For your convenience, Walgreens in Warrenton, VA has a medication collection unit located in their lobby.
Consent
I have read and understand the above information concerning controlled medication.
Your Information
If any controlled medications need to be called into a pharmacy in the future, please list your information below
Preferred Pharmacy
Pharmacy Location
Pharmacy Phone Number
Owner's Birthdate
Date Format: MM slash DD slash YYYY
Owner's Name
First Last

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