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| WEST
VIRGINIA BOARD OF PHARMACY |
| 232 Capitol
Street |
| Charleston,
West Virginia 25301 | |
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| APPLICATION
FOR LICENSE PERMIT OR RENEWAL AS A |
| CONSULTANT
PHARMACIST
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| July 1,
2005 to June 30,
2006 |
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Current
name and address |
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LICENSE #
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PHONE # |
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NOTE: |
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This form must be completed for each institution or facility in
which consultation or coordination is performed. Make as many copies as
necessary. Fee is $20.00 for each facility. |
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Complete the
following information on the institution or facility on behalf of which
consultation or coordination is performed: |
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DBA
Name |
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Phone |
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Address |
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City |
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State |
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Zip |
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County |
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License
issued to institution or facility by Board of Health, Nursing Home Board,
or other Agency: License # ________ State ________ |
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Skilled
Nursing Facility ______ |
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Home for the
Aged ______ |
Hospital
______ |
Rest Home
______ |
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Intermediate
Care Facility ______ |
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Nursing Home
______ |
Clinic
______ |
Government
Agency ______ |
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How are drugs
stored on premises? Specify |
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| How are drugs
supplied and/or dispensed to patients in the facility or
institution? By local pharmacy, where pharmacist is the
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| consultant? Yes__
No__ | |
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Other
(Explain) |
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Does the
facility or institution have a Policies and Procedures Manual for drug
distribution and pharmacy services? Yes___ No___ |
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Does the
facility or institution have a policy on disposition of drugs for
discharged or deceased patients? Yes___ No___ |
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Does
consultant maintain or have access to medical charts and/or patient
profiles? Yes___ No___ |
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Average
contact hours with the facility or institution per week
__________________ |
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Signature of Pharmacist Consultant |
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Signature of Facility Administrator or Authorized
Agent |
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