Controlled Substance RX Information

Please fill out the following form to confirm you understand our controlled substance policy.

Rx

First Name

Last Name

Date of Birth

This controlled substance form is to inform you of the rules and regulations of Quint Family Care as it pertains to the writing of prescriptions for any controlled substance.

Due to strict laws in the state of Georgia concernting the writing of prescriptions for controlled substances, it is necessary for Quint Family Care to monitor patients closely. A personal visit every 3 months is required by the office of Dr Karen Thompson in order to manage patient care while prescribing controlled substances. Quint Family Care has the right to require urine or blood testing at any time and at any interval frequency.

As a patient of Dr Karen Thompson, FNP-C and signing this information form, you consent to regular and routine drug testing.

Initials

I declare that have read and understood the above information as it concerns the rules and regulations of Dr Karen Thompson on prescribing controlled substances.

Your Signature

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Quint Family Healthcare. Your Cave Spring and West Georgia Doctor specializing in Healthcare and Family Medicine.

Controlled Substance RX Information

Rx

15 Cedartown Street Cave Spring, Georgia 706-749-4900 Office 706-749-4901 Fax

15 Cedartown Street
Cave Spring, Georgia
706-749-4900 Office
706-749-4901 Fax