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  • Blank Site Approval Form

    Diunggah oleh

    Bishara Wilson
    10 tayangan1 halaman
    This document contains fields for a doctoral student and medical professional to provide information for an inter-professional communication application. The student must provide their name, term, and year, and the medical professional must provide their name, site details, license information, and sign to agree to allow the student observational access. The signature confirms the student can observe but not treat patients during their time at the site.

    Deskripsi Asli:

    Site approval form for PCOM doctorate

    Hak Cipta

    © © All Rights Reserved

    Format Tersedia

    DOCX, PDF, TXT atau baca online dari Scribd

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    This document contains fields for a doctoral student and medical professional to provide information for an inter-professional communication application. The student must provide their name, term, and year, and the medical professional must provide their name, site details, license information, and sign to agree to allow the student observational access. The signature confirms the student can observe but not treat patients during their time at the site.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    10 tayangan1 halaman

    Blank Site Approval Form

    Diunggah oleh

    Bishara Wilson
    This document contains fields for a doctoral student and medical professional to provide information for an inter-professional communication application. The student must provide their name, term, and year, and the medical professional must provide their name, site details, license information, and sign to agree to allow the student observational access. The signature confirms the student can observe but not treat patients during their time at the site.

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 1

    Applications of Inter-Professional Communication

    Instructions: Upload completed form to Moodle

    Doctoral Student Information

    Name: ______________________ Date:_________

    Fall Winter Spring ___________ (please circle)


    Year

    Medical Professional Information

    Medical Professional Name_________________________________

    Site Name ______________________________________________

    Site Address ____________________________________________

    _____________________________________________

    City _______________ State _______ Zip Code _______

    Contact Person _____________________ Phone (____) _________

    License type _________ License number ___________________

    Other info _______________________________________________

    Site Statement

    The undersigned agrees to allow the Doctor of Acupuncture and Chinese Medicine
    (DACM) student to observe, access facilities, follow rounds, and participate in any other
    appropriate activities in order to facilitate their education. Please be advised that
    doctoral student should observe but are not allowed to treat patients during observation
    hours.
    _____________________________ _____________
    Signature of Medical Professional Date

    _____________________________ _____________
    Printed name Title

    Rev. 9/8/17 CC

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