Protocol agreement approved by: Primary Supervising Physician – Date Original Signature Full Name (typed or printed legibly) Clinical Pharmacist Practitioner – Date Original Signature Full Name (typed or printed legibly) ----------------------------------------------------------------------------------------------------------------------------------------- Back-up Supervising Physician(s): Date Original Signature Full Name or printed legibly) --------------------------------------------------------------------------------------------------------------------- Date Original Signature Full Name or printed legibly) --------------------------------------------------------------------------------------------------------------------- Date Original Signature Full Name (typed or printed legibly)
Protocol agreement approved by: Primary Supervising Physician – Date Original Signature Full Name (typed or printed legibly) Clinical Pharmacist Practitioner – Date Original Signature Full Name (typed or printed legibly) ----------------------------------------------------------------------------------------------------------------------------------------- Back-up Supervising Physician(s): Date Original Signature Full Name or printed legibly) --------------------------------------------------------------------------------------------------------------------- Date Original Signature Full Name or printed legibly) --------------------------------------------------------------------------------------------------------------------- Date Original Signature Full Name (typed or printed legibly)
CPPProtocolExampleFeb2017.docx