Nursing Care Questionnaire - Group Insurance Form Page 2
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2Type of medication, method of administration and frequency ________________________________________________________________________________________
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Specific duties to be performed by the nurse ______________________________________________________________________________________________________
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Additional comments ___________________________________________________________________________________________________________________________
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4. PATIENT CLINICAL INFORMATION
I hereby confirm that the above information is true and complete to the best of my knowledge.
Physician’s name _______________________________________________________________________________________ Telephone
Address _____________________________________________________________________________________________________ Fax
General practitioner
Specialist
Other
Specify ____________________________________________________________________________________
Y
M
D
Signature
Date signed
__________________________________________________________________________________________________________________________________
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