I confirm that the above statements have been explained to me and in this knowledge agree to administration of the product to me/my ward. Patient's name: ……………………………………………………………………………….. Signature of patient: Date: …………………………………………………… …………….. (or parent/guardian) Signature of witness: Date: …………………………………………………… …………….. I have explained the above statements to the patient or the patient's parent/guardian. Treating physician: …………………………………………………………………………... Signature: Date: ………………………………………………………………. …………….. Do Not Send to TGA. Should be kept on file patient’s APPENDIX 4 HREC LETTER OF ENDORSEMENT FOR AUTHORISED PRESCRIBERS
I confirm that the above statements have been explained to me and in this knowledge agree to administration of the product to me/my ward. Patient's name: ……………………………………………………………………………….. Signature of patient: …………………………………………………… Date: …………….. (or parent/guardian) Signature of witness: …………………………………………………… Date: …………….. I have explained the above statements to the patient or the patient's parent/guardian. Treating physician: …………………………………………………………………………... Signature: ………………………………………………………………. Date: …………….. Do Not Send to TGA. Should be kept on patient’s file APPENDIX 4 HREC LETTER OF ENDORSEMENT FOR AUTHORISED PRESCRIBERS