Medication Update - Buprenorphine

*FOR NEW PATIENTS ONLY

Please fill out the form below to update us on your treatment progress. Once we receive your response, your doctor/provider will continue your treatment or make dose adjustments if necessary.

First Name ^*

Last Name ^*

Phone # ^*

Date of Birth ^*

Which formulation are you currently taking? ^*Suboxone FILM (buprenorphine/naloxone) - 8mgSuboxone FILM (buprenorphine/naloxone) - 4mgSuboxone TABLET (buprenorphine/naloxone) - 8mgSuboxone TABLET (buprenorphine/naloxone) - 4mgSubutex TABLET (buprenorphine only) - 8mgSubutex 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?

Today's Date ^*

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

Medication Update – Buprenorphine

*FOR NEW PATIENTS ONLY

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