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Yes

Signature:

Date:

Signature:

Date:

Signature:

Date:

11.

Received or accessed a copy of NHRMC’s Code of Conduct at:  http://www.nhhn.org/body.cfm?id=3166

Yes

12.

Signed and returned the Code of Conduct Acknowledgment Form, also available at http://www.nhhn.org/body.cfm?id=3166, certifying receipt of Code of Conduct and agreement to comply with its contents.

Yes

Date of Signature:

13.

The Pharmacy Manager must approve all appointments scheduled within the hospital with Pharmacy Representatives, including lunch and learn sessions.  

14.

I acknowledge that I have received and read the Manufacturer’s Representative for Invasive and Non-Invasive Procedure policy and thereby agree to abide by it and other system policies pertaining to this matter.

Vendor’s Signature

Date

For Office Use Only

Materials Management

Date

Department Director’s Signature

Date

Need Immunization

Pending/ Missing Information

Approved

Updated 9.1.06

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