Walk-In Clinic Antibiotic Stewardship Pledge Form Template

Antimicrobial resistance is one of the most pressing public health challenges of our time, and walk-in clinics play a crucial role in combating this growing threat. This Walk-In Clinic Antibiotic Stewardship Pledge template helps healthcare facilities formalize their commitment to responsible antibiotic prescribing, evidence-based treatment protocols, and patient education initiatives.

Why Antibiotic Stewardship Matters for Walk-In Clinics

Walk-in clinics and urgent care centers are often the first point of contact for patients with acute infections. With this access comes responsibility—studies show that up to 30% of antibiotics prescribed in outpatient settings may be unnecessary. By implementing structured stewardship programs, clinics can significantly reduce inappropriate prescribing while maintaining excellent patient outcomes.

This pledge template provides a framework for clinics to commit to:

Evidence-based prescription guidelines for common infections
Patient education standards that explain when antibiotics are (and aren't) needed
Resistance monitoring participation to contribute to regional and national surveillance
Staff training commitments to keep teams updated on best practices
Quality metrics tracking to measure and improve stewardship outcomes

How Paperform Streamlines Healthcare Commitments

Managing organizational pledges and compliance documentation can be administratively burdensome, but Paperform makes it simple. This template transforms a complex multi-stakeholder commitment into a clean, professional digital form that walk-in clinics can complete in minutes.

For healthcare administrators and clinic managers, this form captures all essential stewardship commitments in one place—from prescription protocols to staff training schedules. The conditional logic adapts questions based on clinic size, current practices, and specific areas of focus, ensuring relevance without overwhelming busy healthcare teams.

For public health organizations and healthcare networks, collecting these pledges digitally means instant access to participation data, automatic confirmation emails, and the ability to track which facilities have committed to specific initiatives. You can embed this form on your website, send it via email campaigns, or share it during stewardship training sessions.

Automation That Supports Public Health Initiatives

Once a clinic submits their stewardship pledge, the work is just beginning. That's where Stepper (stepper.io) becomes invaluable for healthcare coordinators. You can automatically:

Send pledge confirmations with educational resources and implementation toolkits
Add participating clinics to your stewardship program CRM or database
Schedule follow-up check-ins at 3, 6, and 12-month intervals
Route notifications to regional antimicrobial stewardship coordinators
Generate quarterly reports on pledge participation and commitment areas

For clinics requiring signed agreements or contracts, Papersign (papersign.com) seamlessly converts the pledge submission into a formal eSignature document, creating a legally binding commitment with a complete audit trail—perfect for clinics participating in quality improvement programs or seeking stewardship recognition.

Built for Healthcare Professionals, Not Just Data Collection

This template is designed with healthcare workflows in mind. The form uses clear, professional language that respects the expertise of medical practitioners while providing structure for commitment tracking. Conditional sections ensure that smaller clinics aren't overwhelmed with enterprise-level requirements, while larger facilities can detail more comprehensive programs.

Whether you're a public health department launching a regional stewardship initiative, a healthcare network standardizing practices across multiple locations, or an individual walk-in clinic taking the first step toward formal stewardship, this Paperform template provides the foundation you need.

Trusted by Healthcare Organizations

Paperform is SOC 2 Type II compliant and trusted by healthcare organizations worldwide for secure data collection. With options for data residency, SSO, and enterprise-grade security, you can confidently collect sensitive operational information from participating clinics. All submissions are encrypted, and you maintain complete control over data access and storage.

Getting Started with Stewardship Pledges

This template is ready to use immediately—simply customize the clinic information fields, adjust commitment options to match your stewardship program's priorities, and share with participating facilities. The clean, professional design works beautifully as a standalone landing page or embedded directly into your healthcare organization's website.

By digitizing antibiotic stewardship pledges with Paperform, you're not just collecting signatures—you're building a structured, trackable, and scalable approach to one of healthcare's most important quality initiatives. Start gathering commitments today and contribute to the global fight against antimicrobial resistance.