It is necessary to complete all policy forms and insurance forms in order to proceed with your office visit.

Release of records request
Patient contract
Special population policies
Pregnancy
Concomitant illicit or scheduled medication

Release Requirement

Other Medications and Health Records
Create a list of all your medications including current over the counter and prescription medications. Be sure to list the dosage of each medication. Unexpected drug interactions may lead to serious complications including death. 2nd Chance will also make every effort to obtain any previous health records if you provide permission by signing a release of records request.


​Keep all prescriptions in a safe place to prevent loss, theft, or accidental ingestion by a child.2nd Chance CANNOT replace lost or stolen medication BY LAW.

2nd Chance does not advocate taking other medications that may interact negatively with buprenorphine. If you have been prescribed benzodiazepines, amphetamines, or other scheduled medications you need a consult with a board certified psychiatrist or addictionologist.

Illicit scheduled medication use WILL NOTbe tolerated and may result in dismissal. Disruptive, threatening, or violent behavior will result in my dismissal from the clinic. Any confirmation of diversion will result in dismissal from the clinic and authorities will be contacted.

Once a patient has been seen by a doctor no refunds may be given, even if the patient decides not to continue treatment.

While we respect patient/client confidentiality, any reporting of domestic abuse, child abuse or neglect must be passed on to the appropriate authorities and services.

​​Center for Opiate Addiction Treatment