Name: here to enter text Printed name in full. Signature X____________________________________________ Medical practitioner ______________________________________________ Date of the HREC: I certify that I have read this application, and endorse this application for the above medical practitioner to become an Authorised Prescriber. Name: Click here to enter text Printed name in full. Signature X____________________________________________ Chair of RCH HREC ______________________________________________ Date
Name: Printed name in full. here to enter text Signature X____________________________________________ Medical practitioner ______________________________________________ Date of the HREC: I certify that I have read this application, and endorse this application for the above medical practitioner to become an Authorised Prescriber. Name: Printed name in full. Click here to enter text Signature X____________________________________________ Chair of RCH HREC ______________________________________________ Date
authorised-prescriber-endorsement-form.docx