Verbal Medication Consent Form And Log Of Administration - New York State Office Of Children And Family Services

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OCFS-LDSS-7003 (11/2004)
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
Verbal Medication Consent Form and Log of Administration
Use this form if:
o
A parent or guardian arrives at the program requesting medication be given but does not have
written instructions from the authorized prescriber.
o
A child develops symptoms while in your care that require the administration of an over-the-counter
medication
The medication authorized on this form is valid for one day only. This consent form does not authorize the
administration of the medication listed below on multiple days.
1. Child’s first and last name:
2. Name of medication (including strength): 3. Amount/dosage to be given:
4. Route of administration:
5. Frequency to be administered for today only:
6A. Possible side effects:
See package insert for complete list of possible side effects (must be obtained from medication
package or insert)
AND/OR
6B: Additional side effects:
7. What action should the program take if side effects are noted:
Contact parent
Contact prescriber at phone number provided
Other (describe):
8A. Special instructions:
See package insert for complete list of special instructions (must be obtained from medication package
or insert)
AND/OR
8B. Additional 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.)
9. Provider/Facility name:
10. Facility ID number
11. Facility telephone number:
12. I,
received verbal permission from
(child’s parent or legal guardian)
(name of day care provider)
/
/
to administer the medication listed above on
. The instructions I received from the Parent or Legal Guardian
(date authorized to
give)
match the instructions for use on the medication container. If the instructions do not match, I received verbal or written instructions
from the health care provider or licensed authorized prescriber.
This is a double-sided form
Updated 11/04

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