Over-The-Counter Medication Form printable pdf download

Over-The-Counter Medication Form

Over-the-Counter Medication Form

Name __________________________

Date ___________________________

I give permission for, _________________________________________ to use the following

over-the-counter or external preparations as needed according to the directions for

use on the container. Note: If the directions for use are not specific on the container,

(such as Tylenol for a child under the age of 2), I will need a physician's note with the

appropriate dosage.

*Denotes items that must be supplied by parents. All must be in the original container

clearly labled with the child's name.

* ( ) Acetaminophen

* ( ) Ibuprofen

* ( ) Benedryl

* ( ) Baby Wipes

* ( ) Baby Lotion

* ( ) Baby Powder

* ( ) Sunscreen

* ( ) Insect Repellent

( ) Band-Aids

( ) Neosporin or similar Ointment

( ) Bactine or similar First Aid Spray

Parent Signature ___________________________________________________

This consent is valid for 1 (one) year.

Over-The-Counter Medication Form