Fillable MEDICAL DIRECTOR ACKNOWLEDGEMENT STATEMENT (CHIROPRACTOR) (AZ Radiation Regulatory Agency)

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MEDICAL DIRECTOR ACKNOWLEDGEMENT STATEMENT (CHIROPRACTOR) (AZ Radiation Regulatory Agency)

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MDACK-Chiropractic
MEDICAL DIRECTOR ACKNOWLEDGEMENT STATEMENT
(CHIROPRACTOR)
I, ________________________________, am the designated Medical Director of
(Print Name) (Title)
_______________________________________________. I am:
(Facility Name)
a. A licensed practitioner of the healing arts, qualified to perform these procedures
in accordance with my scope of practice as defined by my licensing board.
b. The licensed practitioner establishing written protocol procedures for each laser
use.
c. The licensed practitioner with the prescribing authority to perform therapeutic
procedures with prescriptive devices. (Class 3b or 4 lasers and Class 2 R-F).
d. Available to provide required functions.
________________________________
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MEDICAL DIRECTOR ACKNOWLEDGEMENT STATEMENT (CHIROPRACTOR) (AZ Radiation Regulatory Agency)

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Completed 20 July 2020

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