Mandy Benson

  
 orthoLA 
 Orthopaedic Sports Medicine, 
 Joint and Hand Specialists 
 PAIN MANAGEMENT AGREEMENT 
 PATIENT NAME Mandy Benson 
 BIRTH DATE 1991 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 #-2016 Jul 15 
 Patient Physician Signature Signature 
 Witness Signature Capis An LAW 
 254 Adam Lodge
Moniqueview, NE 98137 
 Phone: 853-176-9464
 Fax: 
 345-674-9484 
 www.ortho-la.com
