Nurse Practitioner Consent Form

Patient Name:

DOB:

Julie Tomberlin MD PA has on staff advanced practice nurses (Nurse Practitioners) to assist in the delivery of pediatric medical care. Our Nurse Practitioners are Amanda Davis, Mindy Rhodes, and Kelti Haley.

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

I have read the above, and hereby consent to the services of an advanced practice nurse for my child’s healthcare needs.

I understand that at any time I can refuse to see the advanced practice nurse and request to see the doctor, subject to availability.

DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent/Guardian Signature:

Date:

Your information will be encrypted.