I understand that not all patients are accepted into this program.  I understand Dr. Brown will determine my eligibility for acceptance based on 2 factors:

  1. Will this program meet my particular recovery needs?
  2. How likely am I to meet my responsibilities to this program?

I understand that there are alternatives to buprenorphine treatment for opioid addiction including:

  1. Medical withdrawal and drug-free treatment
  2. Naltrexone treatment
  3. Methadone treatment

I understand that medication alone is not sufficient treatment for my disease and I agree to participate in the recommended patient education and relapse prevention program, to assist me in my treatment.

I understand that receiving regular counseling is an important part of this program and that I am required to attend individual or group sessions at least 2 times per month.

I understand the Addiction Recovery Center reserves the right to contact the Virginia Prescription Monitoring Program to ensure your compliance with this treatment program.

I understand that I will be urine drug screened on every visit and that Dr. Brown reserves the right to perform additional testing if he deems necessary.

I understand that Dr. Brown reserves the right to discharge me from the program if I have a positive drug screening (Benzodiazepines, Opiates, Cocaine, or Amphetamine/Methamphetamine, Marijuana) or if I violate any part of this agreement.

I understand that I must be in a state of mild to moderate withdrawal before being admitted into this program.


I understand during Phase I of the program (first 6 months), new patients are seen weekly and transfer patients are seen every other week.

I understand during Phase II of treatment (after 6 months), Dr. Brown will determine the frequency of my office visits based on my treatment plan.  I understand that MOST patients are seen once every 4 weeks, provided there is no relapse history; however this is entirely at the discretion of Dr. Brown.

I agree to keep and be on time to, all my scheduled appointments.

I understand that I must get approval by Dr. Brown to miss or reschedule an appointment and that I MUST call 24 hours prior to my appointment

If I fail to show up for a scheduled appointment or fail to give 24 hours’ notice, I will be charged a $50 late/no show fee which will be due immediately.

If I fail to show up for a scheduled appointment, I will be given one opportunity to reschedule for the next office day.  I understand that if I fail to show up for this appointment , I may be discharged from the program.  I further understand that I may have to repeat the Patient Intake process and will have to pay additional fees to be readmitted to the program (if space is available and not greater than 6 months).

I agree to conduct myself in a courteous manner while in the physician’s office.

I agree to leave all backpacks and large purses in my car.

I agree not to arrive intoxicated or under the influence of drugs.  If I do, the staff will not see me and I will not be given any medication until my next scheduled appointment.

I agree not to deal, steal, or conduct any other illegal or disruptive activities in or in the vicinity of the doctor’s office.


I understand that NO MEDICATION is kept on site including Suboxone, Subutex, or any other Narcotic.

I agree that my prescription can only be given to me at my regular office visits.  Any missed office visits will result in my not being able to get medication until the next scheduled visit.

I agree that the medication I receive is my responsibility and that I will keep it in a safe, secure place.  I agree that lost medication will not be replaced regardless of the reason.

I agree to take my prescribed medication as Dr. Brown has instructed and not to alter my medication schedule without first consulting the doctor.

I agree not to sell, share or give any of my medication to another person.  I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without recourse for appeal or reimbursement.

I agree not to obtain medications from any physicians, pharmacists, or other sources without informing my treatment physician.  I understand that mixing buprenorphine with other medications, especially benzodiazepines, such as Valium, (diazepam), Xanax (alprazolam), Librium (chlordiazepoxide), Ativan (lorazepam), Klonopin, and/or other drugs of abuse including alcohol can be dangerous.  I also understand that a number of deaths have been reported in persons mixing buprenorphine with benzodiazepines.

I understand that I may be discharged immediately if I test positive for any Benzodiazepine.

I understand that the use of buprenorphine/naloxone (Suboxone) by someone who is addicted to opioids could cause them to experience severe withdrawal.