Patient Update Form

Please correct the errors described below.

Name of all associated patients:

Add Information

No Shows and Tardiness

Advanced Practice Nurse Consent for Treatment

This Facility has on staff an advanced practice nurse of assist in the delivery of medical care. Advanced practice 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 servers of an advanced practice nurse for my health care needs.

I understand that at any time I can refuse to see the advanced practice nurse and request to see a physician if a physician is available.

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

Loading...