| It has been shown that alcohol abstinence aids in remaining cocaine abstinent. Disulfiram is an effective aid in achieving alcohol abstinence. By choosing to take disulfiram, I make a choice not to drink.
With that in mind, I,______________________________, agree that if I provide a positive urine sample for cocaine, fail to provide a scheduled sample, or drink to intoxication, I will start disulfiram therapy.
If any of the above occur, I agree to take disulfiram for _______ days. I will follow the procedures for taking disulfiram observed at the clinic and on my own on nonclinic days, and I will comply with blood work as required.
In order to be cleared by a physician to take disulfiram, I will make an appointment with the designated staff for a medical update, and I will complete the laboratory work, if needed, as soon as possible.
Patient Signature:
________________________________
Therapist's Signature:
________________________________
Date:
________
|
