Agreement of Practicing Form

An Agreement of Practicing Form sets out clear expectations between YOU as a Health Practitioner and US as the community YOU serve. By signing, YOU declare that YOUR skills, qualifications, and actions meet OUR standards of care, ethics, and professionalism. This agreement protects both sides — giving US confidence that YOUR practice is genuine, safe, and respectful.

Name

First

Last

Practice Location

Date of Agreement

Signature/Autograph

Witnessed By (Name)

Witness Signature/Autograph

Consent Agreement

I agree to the terms and consent to the conditions outlined above (esignature)

Declaration:

“I accept adherence to the professional standards and ethical guidelines set forth by the community health network. I agree that failure to comply may result in termination of my practicing privileges.”

of By (esignature)

Agree to the above Declaration (esignature)

I Agree