Privileging - Podiatrist
Name
Date
-
Month
-
Day
Year
Date
Check the boxes next to the privileges you seek.
History
Medication review
Cutting and removal of corns and calluses
Trimming, cutting, clipping, or debriding of nails
Cleaning and soaking feet
Use of skin creams
Treatment of warts including plantar warts
Treatment of mycotic nails
Medical translation (enter language)
Other privileges not listed here?
Additional comments:
I attest that I have appropriate training, competence, experience, and comfort level for each privilege requested.
Date
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: