Med Update | CARE Clinic Addiction Treatment

Medication Update

First Name

Last Name

Phone #

Date of Birth

Which formulation are you currently taking?

Suboxone FILM (buprenorphine/naloxone) - 8mg

Suboxone FILM (buprenorphine/naloxone) - 4mg

Suboxone TABLET (buprenorphine/naloxone) - 8mg

Suboxone TABLET (buprenorphine/naloxone) - 4mg

Subutex TABLET (buprenorphine only) - 8mg

Subutex TABLET (buprenorphine only) - 4mg

What is your current dose?

Are you experiencing any side effects or having any problems with your current dosing? (Please describe below)

If you are comfortable with your current dose, which pharmacy would you like your medications sent to?

I declare that the info I’ve provided is accurate & complete

Today's Date

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