Restricted Medication Patient Agreement

This agreement applies to patients prescribed Schedule 8 (S8) controlled substances including opioids (e.g. oxycodone, morphine, fentanyl) and stimulants (e.g. dexamphetamine, lisdexamfetamine, methylphenidate). Please read, tick each item, and sign below.

1. Safe Storage

Store medication in a locked, secure location not accessible to others.

Keep out of reach of children and pets at all times.

Keep in original packaging with dispensing label intact.

Store at the correct temperature as advised by my pharmacist.

Avoid carrying large quantities unnecessarily.

2. Not Sharing, Selling, or Giving Away Medication

This medication is prescribed for me only and must not be given, lent, or sold to any other person.

Supply of an S8 drug to another person is a criminal offence under the DPCS Act 1981 (Vic).

I will not allow others — including family — to access my medication.

3. Single Prescriber & Pharmacy

Obtain prescriptions for this medication from Dr Kenchaiah only, unless otherwise agreed.

Seeking the same S8 medication from multiple prescribers without their knowledge may constitute an offence under the DPCS Act 1981 (Vic) depending on circumstances.

Use a consistent dispensing pharmacy and inform Dr Kenchaiah of any change.

Disclose all other medications prescribed by other doctors, including overseas.

4. Repeat Prescriptions & Early Requests

Prescriptions will be issued at scheduled intervals only and will not be issued early.

Running out early is not grounds for an early prescription.

5. Lost or Stolen Medication

Lost or stolen medication cannot routinely be replaced before the next scheduled date.

A replacement will not automatically be issued for lost or stolen medication.

If stolen, I will report to Victoria Police and provide a report number before any replacement is considered.

Repeated losses may affect continued access to this prescription.

6. Prescription Monitoring (SafeScript)

My prescription is recorded in SafeScript and may be reviewed by authorised prescribers and pharmacists.

I consent to urine or blood drug screening if requested. Refusal may affect access to this prescription.

7. Safe Disposal

Return unused or expired medication to a pharmacy via the Return Unwanted Medicines (RUM) Program. Do not flush or bin.

8. Risks & General Safety

Mixing with alcohol, benzodiazepines, or sedating substances significantly increases overdose risk.

This medication may impair driving; I accept responsibility for assessing my fitness to drive.

I will report changes in health, other medications, or circumstances to Dr Kenchaiah.

Dr Kenchaiah may alter, reduce, or cease this prescription if terms are not met or if clinically indicated.

I have read and understood this agreement in full and agree to abide by all conditions. I understand this forms part of my clinical record.

Date

Patient Signature

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For office use

Prescribing Doctor

Agreement Date

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Restricted MedicationPatient Agreement