Monitoring & Evaluation Consent

Monitoring & Evaluation Consent

Please review and provide your consent by filling out the form below.
Patient Name

First NameLast Name
Start of Care Date*

MonthDayYear
Date
Diagnosis*
Facility Name/Care Home*
Patient Authorization*

I authorize ONEIRO Pharmacy to allow their Licensed Nurses to perform the right practiceI authorize ONEIRO Pharmacy to monitor my physical, mental well-beingI authorize ONEIRO Pharmacy to evaluate my ongoing treatmentI authorize ONEIRO Pharmacy to allow their Licensed Nurses to inform my family about my condition if responsible party presents legally
Legal Responsibility Party Signature*

First NameLast Name
Nurse Signature*

First NameLast Name
Patient Signature*

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