I will not allow any other individual to use my buprenorphine. It is dangerous for an individual not on buprenorphine to ingest the medication. Doing so may result in serious injury or even death for that individual. For Female Patients of Age: To the best of my knowledge, I am pregnant at this time. □ I am not pregnant at this time. □ If I do become pregnant, I will inform my medical provider or one of his/her assistants immediately. For All Patients: Alternative methods of treatment, the potential benefits of treatment, possible risks involved, and the possibility of complications have been explained to me. I certify that no guarantee or assurance has been made as to the results that may be obtained from addiction treatment. Part 5: Sign the form Sign your name and the date. Sign your name: Date: Print your name (First and Last): Address: Doctor Name: Doctor signature: Date: Appendix G: Home induction protocol See PDF Appendix H: Clinical Opiate Withdrawal Scale (COWS) Flowsheet for measuring symptoms over a period of time during buprenorphine initiation. For each item, write in the number that best describes the patient’s signs or symptom. Rate on just the apparent relationship to opioid withdrawal. For example, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score. Patient’s Name: Buprenorphine initiation: Date: Enter scores at time zero, 30min after first dose, 2 h after first dose, etc. Times:
I will not allow any other individual to use my buprenorphine. It is dangerous for an individual not on buprenorphine to ingest the medication. Doing so may result in serious injury or even death for that individual. For Female Patients of Age: To the best of my knowledge, □ I am pregnant at this time. □ I am not pregnant at this time. If I do become pregnant, I will inform my medical provider or one of his/her assistants immediately. For All Patients: Alternative methods of treatment, the potential benefits of treatment, possible risks involved, and the possibility of complications have been explained to me. I certify that no guarantee or assurance has been made as to the results that may be obtained from addiction treatment. Part 5: Sign the form Sign your name and the date. Sign your name: Date: Print your name (First and Last): Address: Doctor Name: Doctor signature: Date: Appendix G: Home induction protocol See PDF Appendix H: Clinical Opiate Withdrawal Scale (COWS) Flowsheet for measuring symptoms over a period of time during buprenorphine initiation. For each item, write in the number that best describes the patient’s signs or symptom. Rate on just the apparent relationship to opioid withdrawal. For example, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score. Patient’s Name: Buprenorphine initiation: Date: Enter scores at time zero, 30min after first dose, 2 h after first dose, etc. Times:
Bup-Implementation%20Manual%20Appendices.docx