There are four different disclosure statements.  One is a general description. The three that follow are slight variations dependent upon the pharmacist’s position. One statement covers an employee pharmacist with a consenting pharmacist in charge (PIC) as their supervisor.  Another is an employee pharmacist with a non-consenting PIC but with a referral to the PIC’s supervisor.  Finally, there is a form for a pharmacist who is the sole PIC.  If you are a (PIC) with ethical objections but are not the sole PIC you can easily modify the “sole PIC” form to conform to your context.  After discussing the material and coming to an agreement with the appropriate person in charge, it is initial and date the pages discussed, and to sign the documents.  Those crafting the disclosure statement should have it reviewed by legal counsel and if questions arise with the appropriate board of pharmacy.  These are suggested forms and are not intended as legal documents, attempts to grant legal advice, or recommendations for specific pharmacy practice.


Exercise of Moral and Professional Conscience: A Pharmacy Practice Disclosure Statement
This template serves as a general guide to accommodate an individual pharmacist’s disclosure of intent to practice pharmacy in accordance with their professional, moral, and ethical conscience.  The non-bolded areas contain basic disclosure information for use in expression of conscience clause statements.  The bolded print indicates sections that can be crafted by an individual pharmacist that reflect to their personal context.

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Exercise of Moral and Professional Conscience: A Pharmacy Practice Disclosure Statement (Pharmacist to Pharmacist-in-Charge)
This template addresses an employee pharmacist with a consenting pharmacist in charge (PIC) as their supervisor.

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Exercise of Moral and Professional Conscience: A Pharmacy Practice Disclosure Statement (Pharmacist to Supervisor)
This template addresses employee pharmacist with a non-consenting PIC but with a referral to the PIC’s supervisor.

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Exercise of Moral and Professional Conscience: A Pharmacy Practice Disclosure Statement (Sole Pharmacist-in-Charge)
This form addresses a pharmacist who is the sole PIC.

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Again please note those crafting the disclosure statement using these sample templates and forms should have their disclosure reviewed by legal counsel and also if their appropriate board of pharmacy.  These are suggested forms and are not intended as legal documents, attempts to grant legal advice, or recommendations for specific pharmacy practice.