NURSE PRACTITIONER CONSENT - Pediatric Associates of Abilene

ADVANCE PRACTICE NURSE

Advance Practice Nurse Consent for Treatment

This facility has on staff an advance practice nurse to assist in the delivery of medical (may indicate specialty) care.

An advance practice nurse in not a doctor. An advance practice nurse is a registered nurse who has received advanced education and train ing in the provision of health care. An advance practice nurse can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. In addition, the advance practice nurse may treat minor lacerations and other minor injuries.

I have read the above, and hereby consent to the services of an advance practice nurse for my health care needs.

I understand that at any time I can refuse to see the advance practice nurse and request to see a physician.

ONLINE SUBMISSION: I acknowledge that I have read and fully understand this Authorization form. I fully understand the risks and benefits of submitting personal information online. I agree that I understand the risks associated with online communications between my physician and patient, and consent to the conditions outlined herein. I agree not to hold The Professional Association for Pediatrics or any of its staff or physicians liable for network or security infractions beyond their control. Online form submission is entirely voluntary and will not impact the quality of care I receive from The Professional Association for Pediatrics should I decide against using these services. In addition, I agree to adhere to the policies set forth herein, as well as any other instructions or guidelines that my physician may impose for online communications.

By checking this box you agree to the above, our Office Policy and agree that the information provided in this form is truthful and correct.

Child's Name

Date

Parent's Name

All articles and any forms, checklists, guidelines and. materials are for generalized information only, and should not be reviewed or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. They are intended as resources to be selectively used and always adapted – with the advice of the organization’s attorney – to meet state, local, individual organization and department needs or requirements. They are distributed with the understanding that neither Texas Medical Liability Trust nor Texas Medical Insurance Company is engaged in rendering legal services.