Pharmacy Technician Enhanced Training: Point-of-Care Testing Consent, Waiver, and Release
To be completed by the Participant
Sign in to Google to save your progress. Learn more
Email *
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 this Consent, Waiver, and Release, completed online by the Participant
  • a copy of Consent, Waiver, and Release, completed online separately 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 Participant) 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. 
Participant Name *
Mailing Address *
Email *
Phone Number *
By checking "I agree", the Participant consents and agrees to the following:

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.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms