Medication must
have child’s first and last name on container.
·
Medication must be
prescribed by a physician.
·
Medication must be
in a child-proof container.
·
Medication must
have date filled and expiration date on container.
·
Over the counter
medicine must have instructions for giving, storing and disposing.
·
NO MEDICATION
MAY GIVEN WITHOUT PHYSICIAN SIGNATURE.
Physician Signature:__________________________________
Date:____________
Medication:_____________________________________________________________
Child’s Full
Name:_______________________________________________________
Please
tell us about this medication:
Condition
for which
prescribed:______________________________________________________
Possible
Side
Effects:______________________________________________________________
Dosage
and Time (s) of
administration:_______________________________________________
Date Filled:___________________________________
Expiration Date:_____________________
Days
to be given:
Monday_________
Tuesday________ Wednesday_________ Thursday________ Friday_______
Other
Remarks:__________________________________________________________________
I, __________________________
(parent/guardian name) give permission for the above medication
to be given to my child as prescribed by _________________________(name
of Physician). This
medication
may be given until ________________________ (date or
when empty).
Parent/Guardian
Signature:_____________________________________
Date:______________