SUBOXONE THERAPY

TERMS AND AGREEMENTS

**PLEASE SCROLL TO THE BOTTOM OF THE PAGE AND E-SIGN TO AGREE.**

**Before we SCHEDULE YOUR APPOINTMENT, PLEASE READ ALL TERMS AND AGREEMENTS.**

 


nECESSARY DOCUMENTS

PLEASE ARRIVE WITH THE FOLLOWING DOCUMENTS:

  1. PHOTO IDENTIFICATION CARD 
  2. INSURANCE CARD
  3. PHARMACEUTICAL BENEFITS CARD

PAYMENT AND INSURANCE INFORMATION

NEW PATIENTS

  • 1st Visit: $280
  • Every Subsequent Visit: $110

We accept CASH, CREDIT, and DEBIT


URINE DRUG SCREENING

  Each Visit, all patients will be required to give a urine drug screen, prior to being seen by the doctor.

  • To monitor the types of medications our patients are taking (Combining certain medications  can cause dangerous health complications)
  • To assess compliance with our treatment regimen
  • To assure that patients are not using the medications for illicit purposes

Patients should be aware that inconsistent drug screens (presence of an illegal substance, presence of a substance not prescribed, and/or absence of substance that should be present in a drug screen) are grounds for dismissal.

IMPORTANT NOTICE!

**Patients who are unable to urinate will experience a delay to see the doctor and there will be a $20 charge as the urine test will to be replaced with an oral swab test.**


MISSED APPOINTMENTS

If you miss or cancel your scheduled appointment, you will be charged a $25 fee.

What qualifies as a "missed or cancelled appointment"?

  • Notifying our office of a cancellation with less than 48 hour notice.
  • Not showing up at your scheduled appointment time.
  • Coming to your appointment after our office has closed for the day.
  • Not seeing the Doctor on your scheduled appointment date and time
  • If you come late and the doctor is no longer there

If your appointment is scheduled within the last half hour of our session times you must have your phone available.

Please make note and be aware of our office session hours.  We may call our patients to come in earlier than their scheduled appointment. If your phone IS NOT available, and there has been a change of your appointment for an earlier time, this may result in a missed appointment fee.

 


PLEASE E-SIGN BY FILLING OUT ALL INFORMATION BELOW

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