Pharmacy Technician Enhanced Training: Point-of-Care Testing Consent, Waiver, and Release
To be completed by the Preceptor
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General Information
Surgent PharmCon, LLC (“PharmCon”) offers a training program titled “Pharmacy Technician Enhanced Training: Point-of-Care Testing” (the “Training”).  As part of the Training, the Pharmacy Technician participant (the “Participant”) and supervising pharmacist (the “Preceptor”) are required to submit the following to PharmCon:
  • a copy of Consent, Waiver, and Release, completed online separately by the Participant
  • a copy of this Consent, Waiver, and Release, completed online by the Preceptor
  • a copy of the Attestation form, completed online by the Preceptor
Please complete all of the information required, carefully read and agree where indicated. By agreeing to the terms listed below, you (the Preceptor) consent and agree to the waivers, releases and other provisions set forth below. Failure to complete and/or submit these items to PharmCon may result in denial of training completion certificate. 
Preceptor Name *
Mailing Address *
Email *
Phone Number *
Pharmacy License Number *
State of Licensure *
By checking "I agree", the Preceptor consents and agrees to the following:

1.   Licensing Attestation. I attest that I am a licensed pharmacist in good standing, and that the pharmacy license information provided above is true and correct.

2. Supervision of Participant.  I agree to provide appropriately supervise the Participant in the provision of point-of-care testing.  I am responsible for ensuring that the Participant is provided with appropriate supplies.
 
3. Waiver and Release.  I release PharmCon, its affiliates and commercial partners, and their respective officers, directors, employees and agents (collectively, the “PharmCon Parties”) to the fullest extent under applicable law, from any and all liability, claims and actions that may arise from or relate to any injury or harm to me or others, or any other damages I may suffer in connection with my participation in the Training, including, but not limited to, in connection with the provision of point-of-care testing in connection with the Training.  I recognize that this release means that I am giving up, among other things, rights to sue any of the PharmCon Parties for injuries, damages or losses I may incur while participating in the point-of-care testing training program. I agree that this release is binding on me and my heirs, executors and assigns. 
 *
A copy of your responses will be emailed to the address you provided.
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