Request For The Administration Of Prescription Medication printable pdf download

Request For The Administration Of Prescription Medication

Sample Form

Office of Early Learning and School Readiness

REQUEST FOR THE ADMINISTRATION OF PRESCRIPTION AND NON-PRESCRIPTION MEDICATION,

FOOD SUPPLEMENT, FLOURIDE SUPPLEMENT, OR MODIFIED DIET

NOTE: A separate form must be completed for each medication.

SECTION I: PARENT REQUEST FOR ADMINISTRATION OF MEDICATION OR SUPPLEMENT

I hereby request and give permission to the authorized staff member to administer the following medication to my child:

Name of Child

Age of Child

Name of Medication or Supplement to be administered

Dosage

Time(s) of Dosage

Signature of Parent/Guardian

Date

SECTION II: PHYSICIAN'S OR DENTIST'S INSTRUCTIONS:

Name of Child: _______________________________________________________is under my care and should receive

Name of Medication or supplement_____________________________________________________________________

Dosage: _______________________________________________________________________________________

Specific instructions for

administration:______________________________________________________________________

Possible side effects:

_______________________________________________________________________________________

Signature of Physician/Physician Assistant/Clinical Nurse Specialist/Certified Nurse or Dentist

Phone #

Please Print Physician's/Dentist's Name

Date

SECTION III: LOG OF MEDICATION OR SUPPLEMENT ADMINISTERED BY AUTHORIZED STAFF MEMBER

Date and Time of Dosage

Amount of Dosage

Signature of Authorized Staff Member

Date and Time of Dosage

Amount of Dosage

Signature of Authorized Staff Member

Request For The Administration Of Prescription Medication