Medical Intake Form

Full Name

Preferred First Name

Date of birth

Sex *

Male

Female

Preferred Pronouns

Mobile Phone *

Home Phone *

Email *

Consent to text and call appoinment reminders?

Insurance Information

Insurance Type

Insurance ID / Certificate #

Medical Insurance Name *

Behavioral Insurance Name

Relationship to Guarantor

Self

Other

Guarantor Full Name

Guarantor DOB

Guarantor Mailing Address

Guarantor Mailing City

Guarantor Mailing State

Guarantor Mailing Zip

Additional Information

Primary Care Provider name (PCP)

SaVida Treatment Policies
BUPRENORPHINE/NALOXONE

The success of your treatment and recovery is dependent on your adherence to our treatment program and
our policies. You are expected to:

Be on time for appointments. Part of recovery is being able to be accountable. If you must cancel, provide 24 hours-notice so we may fill your appointment slot.
Notify SaVida Health of any change in address or phone number.
Do not arrive at the office intoxicated or under the influence of drugs. If you are intoxicated, we may not be able to provide your buprenorphine/naloxone prescription that day.
Keep all medications in a safe place. SaVida is not responsible to replace lost/stolen medication.
Do not share your medication. This may result in the person’s overdose or death. Immediately call 911 for assistance, even if there are no obvious signs of distress.
Bring your buprenorphine bottle, blister-packs, or films/wrappers (both opened/unopened) to each visit, in the appropriate labeled container. We want to ensure you are responsibly taking of your meds.
Do not tamper with any urine drug screens. It is important for us to understand where you are in your recovery of if there has been a relapse. This will enable us to provide you with the best possible care.
Take your medicine as instructed. If your urine doesn’t show that buprenorphine is present, or if the buprenorphine/norbuprenorphine levels are negative or below the expected levels, you may be required to come to the office for Observed Dosing.
Come into the office when contacted to do so. We may ask you to come into the office for an unplanned (random) drug screen to ensure you are in recovery.
Inform SaVida Health of any new medications or medical conditions, and any adverse effects you experience from the medications you take. There are very rare drug interactions, but it is important that ALL your providers are aware of whatever medications you are taking.
Inform SaVida Health of any upcoming surgeries or dental work so that SaVida may coordinate planning with your other treatment providers. This should be done before pain medication prescriptions are filled at a pharmacy. It may not be safe to take buprenorphine/naloxone and pain medication simultaneously, and the pain medication should be used with caution. If a doctor or dentist gives you a pain medication prescription, you do not need to fill it. When there are significant pain issues and medication is necessary, SaVida will try to coordinate care with the provider to understand how buprenorphine/naloxone works and what your needs are.
Inform SaVida of any vacations or trips prior to leaving the area. Proof of the trip will be requested.
Do not eat foods containing poppy seeds while in treatment These may impact your UDS test results.
Agree to participate in counseling, as appropriate. Counseling in combination with medication has proven to be the most effective treatment for substance use disorder.

What to Expect

While everyone’s treatment plan is individualized, a typical treatment plan includes the following phases:

Induction Phase

Intake/Initial Appointment: history, physical exam, lab draw (blood draw), urine drug test/alcohol screen, meeting with a medical provider
Induction Appointment: 1- 3 days after initial intake; some patients may qualify for a home induction but may still be required to have one day of observed dosing in the office to ensure proper use.
Medication and Symptom Evaluation: 5-7 days after induction.
Behavioral and Case Management Appointment(s)

Stabilization Phase (weekly appointments):

Minimum Time in Phase: 8-12 weeks; except for transfer patients
Typical Criteria for Next Phase (biweekly):
- 8 consecutive urine drug screens negative for substances of abuse
- 8 counseling/case management sessions
- able to maintain safety/security of prescription (i.e. not lost/stolen)
- able to routinely keep all scheduled appointments
- able to maintain stable/safe housing
During this phase you will have weekly visits. You may need to come in more frequently than weekly depending on your progress.

Maintenance Phase (biweekly or monthly appointments):

Once stabilized, patients may move from weekly to bi-weekly and then to monthly.
Improvements in markers of recovery: e.g. resolved legal issues, verified employment, disability status, enrolled student status, appropriate custodial parenting dictate how quickly a patient can be moved to monthly.
Counseling/case management sessions as recommended but no less than quarterly.
Each patient receives a Semi-Annual Treatment Plan Review (every 6 months). This is a more complex visit involving your entire treatment team: prescriber or regular medical provider, case management, and review with behavioral health collaboration team member (as applicable).

You should not take any other medications without first discussing with your healthcare provider.

CONSENT FOR TREATMENT WITH BUPRENORPHINE AT SAVIDA HEALTH, PC

Buprenorphine is an FDA approved medication for treatment of people with opioid use disorder.

You can become dependent on buprenorphine/naloxone. Buprenorphine treatment does result in physical dependence—
meaning you will need to take it to feel well and not be in withdrawal. If buprenorphine is suddenly discontinued, patients
may have symptoms such as muscle aches, stomach cramps, or diarrhea lasting several days. To minimize the possibility
of withdrawal symptoms, tapering and discontinuation should be a slow process and close monitoring is recommended.
Buprenorphine tapering generally occurs over several months.

If you are dependent on opioids, you must be in withdrawal when you take the first dose of buprenorphine. If you are not
in withdrawal, buprenorphine can cause severe opioid withdrawal symptoms.

It may take several days to get used to the transition from the opioid previously used to buprenorphine. During this time, any use of other opioids may cause an increase in symptoms.

After becoming stabilized on buprenorphine, the use of other opioid will have less effect. Attempts to override the buprenorphine by taking more opioids could result in an opioid overdose and can be fatal.

Combining buprenorphine with alcohol or other medications may be hazardous. Combining buprenorphine with benzodiazepine medications such as Xanax, Klonopin, Valium, Haldol, Librium and Ativan can be dangerous without proper medical supervision.

Buprenorphine tablets or film must be held under the tongue until they completely dissolve; buprenorphine will not be absorbed from the stomach if it is swallowed intact. Injecting your medication can cause a number of medical complications and can be hazardous. Like all opioids, patients may suffer side effects such as constipation, dry mouth,
nausea, and headache.

I hereby authorize and give voluntary consent to SaVida Health and its medical personnel to prescribe buprenorphine as part of the treatment for my opiate dependence. I understand there are potential risks and benefits. Treatment procedures have been explained to me, and I understand that this will involve my taking buprenorphine at the schedule determined by my medical provider in accordance with Federal and State regulations. I understand that I my leave the program at any time with or without a supervised tapering of my buprenorphine dose.

Patient Signature* *

Clear

Patient Name *

Date *

INFORMED CONSENT FOR HIV TESTING

My signature below indicates that:

I agree to be tested for HIV
I have been given information about the test.
All of my questions about the test have been answered.
I understand that this consent will expire one year from the date it is signed. I understand I may withdraw my consent at any time.
My decision to be tested is completely voluntary.

HIV Testing Consent Signatures

Patient Signature* *

Clear

Patient Name *

Date *

INFORMED CONSENT FOR HEPATITIS C TESTING

My signature below indicates that:

I agree to be tested for Hepatitis C.
I have been given information about the test.
All of my questions about the test have been answered.
I understand that this consent will expire one year from the date it is signed. I understand I may withdraw my consent at any time.
My decision to be tested is completely voluntary.

Hepatitis C Testing Consent Signatures

Patient Signature* *

Clear

Patient Name *

Date *

Tuberculosis Risk Assessment

Use this tool to identify asymptomatic adults and children for testing for latent TB infection (LTBI).
Re-testing should only be done in persons who previously tested negative, and have new risk factors since the last assessment.
For TB symptoms or abnormal chest X-ray consistent with active TB disease Evaluate for active TB diseases.
Evaluate for active TB disease with a chest X-ray, symptom screen, and if indicated, sputum AFB smears, cultures and nucleic acid amplification testing (NAAT). A negative tuberculin skin test or interferon gamma release assay does not rule out active TB disease.

Check appropriate risk factor boxes below. Latent TB infection testing is recommended if any of the 3 boxes below is checked. If latent TB infection test result is positive and active TB disease is ruled out, treatment of latent TB infection is recommended. REPORT Latent TB Infection and Active or Suspected Active TB Disease

Born or lived in a country with an elevated TB rate *

Yes

Includes any country other than the United States, Canada, Australia, New Zealand, or a country in western or northern Europe.

If resources require prioritization within this group, prioritize patients with at least one medical risk for progression (see User Guide for list).
Interferon Gamma Release Assay (IGRA) is preferred over Tuberculin Skin Test (TST) for foreign-born persons >2 years old. The TST is an acceptable test for all ages when administered and read correctly.

HIV infection, organ transplant recipient; treated with TNF-alpha antagonist (e.g., infliximab, etanercept, others), steroids (equivalent of prednisone ≥15 mg/day for ≥1 month) or other immunosuppressive medication

(For Provider to Complete ) Check below if: *

No TB risk factors. TB test not indicated; no TB test done.

Tuberculosis Risk Assessment Signatures

Patient Signature* *

Clear

Patient Name *

Date *

Location

Please carefully select the SaVida Health Location you wish to visit.

Your SaVida Health Location *