Ala. Admin. Code r. 630-X-A-5
Rule 630-X-5-.08
Appendix B
PROTOCOL FOR THE THERAPEUTIC USE OF PHARMACEUTICAL AGENTS FOR THE TREATMENT OF DISEASE OF THE EYE AND ITS ADJACENT STRUCTURES
Prior to board approval for the therapeutic use of pharmaceutical agents, this Form must be completed and approved by the board. In the case that the board does not approve your protocol, this form or a copy thereof will be returned to you with the reasons it was not approved. You may then correct the problem areas and reapply.
Name:
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Mailing address:
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Physical location of each place you practice (use other side if needed):
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License number:
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Social Security number:
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Office telephone number:
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Do you have an arrangement whereby your patients and/or emergencies are covered if you are unavailable?
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Have all of your staff been instructed in whom to call and how to handle a medical emergency in your office?
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Please attach a written copy of these instructions.
Do you have 24 hour access to your office?
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If not, please give a brief explanation of arrangements you have made to care for after hours emergencies:
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Is there a person in your office (either yourself or a fulltime staff person) who has had CPR training?
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Signature/date