Medication Consent Form
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1
2Medication Consent Form
Handout 2.3
This form must be completed in English.
One form must be completed for each medication. Multiple medications cannot be listed on one consent form.
Parent MUST complete #1-#17 and #19-#22 for medication to be administered 10 working days or less. Parent may omit #16 and #17 for
over-the-counter medications, sunscreen & topically applied insect repellent.
Health care provider MUST complete #1-#18 for medication to be administered more than 10 working days, nebulizer or epinephrine
auto-injector medication, and when dosage directions state “consult a physician”. Parent must also complete #19-#22 in these cases.
Health care providers do not need to complete this form for over-the-counter medications/products applied to the skin.
1
2. Date of birth:
3. Child’s known allergies:
. CHILD’s first and last name
:
4.
):
5.
6.
(including strength
Name of MEDICATION
Amount/DOSAGE to be given:
ROUTE of administration:
7A.
: ________________
or
(e.g. 1p.m.):
FREQUENCY
Specific TIME(s)
____________________________
to administer
Parent’s signature approving Specific Time(s)_______________________
OR
7B. Identify the
of medication:
(signs and symptoms must be
symptoms that will necessitate administration
observable and, when possible, measurable parameters)
.
8.
: □ See package insert
AND/OR additional side effects:
(parent must supply)
Possible side effects
9. What action should the child care provider take if side effects are noted:
□
Contact parent
□
Contact prescriber at phone number provided below
□
Other (describe):
10.
: □ See package insert
AND/OR Additional special instructions:
(parent must supply)
Special instructions
(Include any concerns related to possible interactions with other medication the child is receiving or concerns regarding
the use of the medication as it relates to the child’s age, allergies or any pre-existing conditions. Also describe situations
when medication should not be administered.)
11.
Reason the child is taking the medication (unless confidential by law): _________________________________
12.
Does the above named child have a chronic physical, developmental, behavioral or emotional condition expected to
last 12 months or more and require health and related services of a type or amount beyond that required by children
generally?
□ No □Yes If you checked yes, complete #25 and #27 on the back of this form.
13.
Are the instructions on this consent form a change in a previous medication order as it relates to the dose, time or
frequency the medication is to be administered?
□ No □ Yes If you checked yes, complete #26 and #27 on the back of this form.
14. Date consent form completed:
15.
Date to be discontinued or length of time in days to be given
(this date cannot
exceed 12 months from the date authorized or this order will not be valid):
16.
:
17.
:
(please print)
Prescriber’s name
Prescriber’s telephone number
18.
:
Licensed authorized prescriber’s signature
Required for long-term medications, nebulizer or epinephrine auto-injector medications and when dosage directions state “consult a
skin.
physician”. Not required for over-the-counter medications/products applied to the
Version 12/31/2015
This is a double-sided form
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