MEDICAL DIRECTOR ACKNOWLEDGEMENT STATEMENT
(COSMETIC LASER FACILITY)
I, ________________________________, am the designated Medical Director of
(Print Name) (Title)
_______________________________________________. I am:
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
c. The licensed practitioner with the prescribing authority for prescription medications,
d. The licensed practitioner, who shall assess and document all non-practitioner’s
competency and adequacy of training to perform the ordered treatment safely, with
direct on the job supervision for a minimum of 24 hours for each procedure.
e. The licensed practitioner, who shall provide DIRECT on site supervision of any
cosmetic laser procedure other than laser hair removal, and indirect supervision for
hair removal procedures.
f. I have provided documentation showing I received at least 24 hours of didactic
training on the subjects listed in Appendix C. (In accordance with A.A.C. R12-1-
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