It’s A Secret Academy
Physician Authorization Form

This form must be completed for each PA, NP, RN, or other non-independent practitioner registering for an IAS Academy course.

It’s A Secret Academy
104 Decker Court, Suite 200
Irving, TX 75062
Phone: (469) 639-2011

RE: Acknowledgement and Authorization for Hands-On Training. Please complete for each PA, NP, or RN registering.

"*" indicates required fields

Participant Name and Credentials*

Course Location*

Course Date*

Practice Name*

Practice or Physician Email*

Practice Address*

Street Address Address Line 2 City State / Province ZIP / Postal Code

Supervising Physician Name & Credentials*

Supervising Physician Signature*

Today's Date*

Comments

This field is for validation purposes and should be left unchanged.

It’s A Secret AcademyPhysician Authorization Form