- PRACTITIONER'S AGREEMENT OF
RESPONSIBILITY -
Only licensed health care practitioner's may order prescription medicines. A "health care practitioner" is defined by the state of Georgia as a Medical Doctor (MD), Doctor of Osteopathy (DO), Dentist (DDS,DMD), Podiatrist (DPM) or Veterinarian (DVM). MAP is unable to accept the signature of Registered Nurses, Physician Assistants or Pharmacists. If you will be requesting only non-prescription medicines and medical supplies, this form will not need to be completed. However, all recipients requesting prescription medicines and medical supplies must fully complete this form, including the practitioner's signature and current license number. MAP may periodically call State Medical Boards to verify that all license number are current.
By completing and signing this form, the practitioner assumes full responsibility for MAP International donated prescription medicines and medical supplies to be used in mission work outside of the United States of America. In compliance with the Food, Drug and cosmetic Act, as amended, and Internal Revenue Service regulations, these medicines and supplies will not be used, marketed or returned to the United States, nor be sold or exchanged for property or services. All medicines and medical supplies will be used only in treating the ill, the needy and infants. If these supplies are lost, misplaced, or stolen prior to arriving at their ultimate destination, immediately report this to MAP International by phone (1-912-265-6010) or fax (1-912-261-9963).
Type of Licensed Practitioner: ( )MD ( ) DO ( ) DDS ( ) DMD ( ) DPM ( ) DVM
| Print Name of Ordering Practitioner | Address Of Ordering Practitioner | |
| Signature of Ordering Practitioner | Address (Cont.) | |
| State or Country In Which Licensed | Telephone Number | |
| License Number/Expiration Date | Fax Number | |
| Specialty | Other Contact Number | |
| Print Name of Dispensing Licensed Practitioner | Country Where Supplies Will be Used |
NOTE: A physician licensed in country which does not issue registration numbers must submit a copy of his or her license or certificate to practice medicine.
If prescription medicines are not to be shipped directly to you, the ordering practitioner, the name and address of the individual authorized to receive any prescription medicines under your name must be provided below:
| Name |
| Address |
Address
|