MAT Patient Information Sheet for Initial Visit


The following are required of patients who are admitted to MAT treatment:

  Actively addicted to opioids/heroin or currently taking methadone

  Initial long appointment, includes physical

  Daily follow-up visits at first

  At least monthly visits thereafter

  Random urine and oral testing

  Regular attendance to group or 12-step recovery program

  Release to talk to all other doctors and counselors

  25 dollar refundable deposit when making the appointment

 

PATIENT INFORMATION:

NAME:                 DOB:   

ADDRESS FOR MAIL:

                                     

TELEPHONE (home):                    (work):

OK to leave message?

                   

Does phone require caller ID?

 

INSTRUCTIONS FOR INITIAL APPOINTMENT

  Full bladder

 Bring completed forms or come early

 Withdrawal, (if methadone, more than 24 hours since dose)

 Bring ALL pill bottles

 Valid photo ID

 Will be breath tested for drug and alcohol

 Payment of fees

 

Leave this empty:

Metamorphosis Pain Management https://www.metamorphosispain.com
Signature Certificate
Document name: MAT Patient Information Sheet for Initial Visit
Unique Document ID: 9241cd77e32d0955c6ee2d388a825d6bf5e8226c
Timestamp Audit
2017-05-13 11:34:36 MSTMAT Patient Information Sheet for Initial Visit Uploaded by Lisa Pearson - lisa@metamorphosispain.com IP 208.117.75.130