The University of Kansas - Non-Traditional Pharm.D Program   Clinical Portfolio - Signature Form for Online Portfolio REQUIRED before Portfolio will be considered complete. Print this form directly out of your browser window, complete, sign and have your local preceptor sign. Fax to Prof. Dahm at 913.393.9848

Student:	_________________________________________________
Rotation Location:	_________________________________________________
Patient Name (Initials):	_________________________________________________
Age:	_________________________________________________
Date of Visit/Admission:	_________________________________________________
I affirm that the ideas are my original ideas and the work contained in this clinical portfolio was done by me with the help of my preceptors and I received no help from other students in the NTPD program.
NTPD Student:	_________________________________________________
Date:	_________________________________________________
I precepted this student in the completion of this portfolio and the data provided herein is factual to the best of my knowledge. This patient was an actual patient treated at this site.
NTPD Preceptor:	_________________________________________________
Date:	_________________________________________________