Monitoring & Evaluation Consent
Please review and provide your consent by filling out the form below.
Patient Name
First Name
Last Name
Start of Care Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Diagnosis
*
Facility Name/Care Home
*
Patient Authorization
*
I authorize ONEIRO Pharmacy to allow their Licensed Nurses to perform the right practice
I authorize ONEIRO Pharmacy to monitor my physical, mental well-being
I authorize ONEIRO Pharmacy to evaluate my ongoing treatment
I 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 Name
Last Name
Nurse Signature
*
First Name
Last Name
Patient Signature
*
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Should be Empty: