Jerry Santos

  
 orthoLA 
 Orthopaedic Sports Medicine, 
 Joint and Hand Specialists 
 PAIN MANAGEMENT AGREEMENT 
 PATIENT NAME Jerry Santos 
 date of birth 1990 May 09 
 The purpose of this agreement is to prevent misunderstandings about certain medications you will be taking for pain 
 management. This document will ensure that you and your doctor comply with the laws regarding controlled medications. 
 All of my questions and concerns regarding treatment have been answered adequately. A 
 copy of this document will be provided to me upon signing. This agreement is entered into and becomes effective when 
 signed and remains in effect throughout my treatment period. 
 Date #-2021 Aug 24 
 Patient Physician Signature Signature 
 Witness Signature Capis An LAW 
 3227 Katherine Park
East Laura, VT 87047 
 Phone: 395-767-8234
 Fax: 
 351-143-4148 
 www.ortho-la.com
