Medication Consent Form (Page 2 of 2) in pdf

OCFS-LDSS-7002 (5/2015) REVERSE

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

MEDICATION CONSENT FORM

CHILD DAY CARE PROGRAMS

PARENT COMPLETE THIS SECTION (#19 - #23)

19. If Section #7A is completed, do the instructions indicate a specific time to administer the medication? (For example, did the licensed

authorized prescriber write 12pm?)

Yes

N/A

Write the specific time(s) the child day care program is to administer the medication (i.e.: 12 pm):

20. I, parent, authorize the day care program to administer the medication, as specified on the front of this form, to (child’s name):

21. Parent’s Name (please print):

22. Date Authorized:

23. Parent’s Signature:

CHILD DAY CARE PROGRAM COMPLETE THIS SECTION (#24 - #30)

24. Program Name:

25. Facility ID Number:

26. Program Telephone Number:

27. I have verified that (#1 - #23) and if applicable,(#33 - #36) are complete. My signature indicates that all information needed to give

this medication has been given to the day care program.

28. Staff’s Name (please print):

29. Date Received from Parent:

30. Staff Signature:

ONLY COMPLETE THIS SECTION (#31 - #32) IF THE PARENT REQUESTS TO DISCONTINUE THE MEDICATION

PRIOR TO THE DATE INDICATED IN (#15)

31. I, parent, request that the medication indicated on this consent form be discontinued on

(Date)

Once the medication has been discontinued, I understand that if my child requires this medication in the future, a new written medication

consent form must be completed.

32. Parent Signature:

LICENSED AUTHORIZED PRESCRIBER TO COMPLETE, AS NEEDED (#33 - #35)

33. Describe any additional training, procedures or competencies the day care program staff will need to care for this child.

34. Since there may be instances where the pharmacy will not fill a new prescription for changes in a prescription related to dose, time or

frequency until the medication from the previous prescription is completely used, please indicate the date you are ordering the change in

the administration of the prescription to take place.

DATE:

By completing this section, the day care program will follow the written instruction on this form and not follow the pharmacy label until the

new prescription has been filled.

35. Licensed Authorized Prescriber’s Signature:

Medication Consent Form Page 2