Mrs. Amy Baker

  
 orthoLA 
 Orthopaedic Sports Medicine, 
 Joint and Hand Specialists 
 PAIN MANAGEMENT AGREEMENT 
 PATIENT NAME Mrs. Amy Baker 
 D.O.B 06-04-1996 
 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 #-02-03-2015 
 Patient Physician Signature Signature 
 Witness Signature Capis An LAW 
 65697 Munoz Mountains Apt. 730
West Kevin, PA 52201 
 Phone: 734-815-1561
 Fax: 
 299-700-4693 
 www.ortho-la.com
