Protocol Form For Prescription Of Schedule Ii Controlled Substance Drugs Page 2

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The parties agree that meaningful consultation will best be conducted face-to-face or via
telephone. Consultations may occur spontaneously, as needed, in addition to scheduled
interactions.
•
A copy of this completed protocol/agreement will be available at each site where the advanced
practice registered nurse (APRN) is providing patient care.
•
Either party may rescind this agreement at any time. The preferred method will be in writing.
•
The Nevada State Board will be notified within twenty-four (24) hours of any changes to this
protocol/agreement.
_______________________________________________
________________________
Advanced Practice Registered Nurse
Date
_______________________________________________
_________________________
Collaborating Physician
Date
_________________________________________________________________________________
Practice Location (Address, City, State, Zip Code)
_______________________/__________________________
Practice Phone
Fax Number

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