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Verbal Medication Consent Form And Log Of Administration - New York State Office Of Children And Family Services Page 2

OCFS-LDSS-7003 (11/2004)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

Verbal Medication Consent Form and Log of Administration

13. COMPLETE THIS SECTION FOR VERBAL MEDICATION CONSENTS REQUIRING HEALTH CARE PROVIDER

INSTRUCTIONS

In addition to the above parent/guardian consent I,

received verbal instructions from

(name of day care provider)

(check the credentials of person)

Physician

Physician Assistant (PA)

Nurse Practitioner (NP)

Registered Nurse on behalf of the child’s physician, PA or NP

to administer the medication listed above on

. A request was made to have the

(date authorized to give)

health care provider send the medication instructions in writing.

14. Licensed prescriber’s name (physician, PA or NP):

15. Licensed prescriber’s telephone number:

16. I have verified that sections #1 - #15 are complete. My signature indicates that all information necessary to safely administer this

medication has been given to the day care program.

17. Authorized child care provider’s name (please print):

18. Date received from parent:

19. Authorized child care provider’s signature:

Document the administration of the medication in the log below

Date Given

Medication

Dose

Time Given

Signature of Day Care Provider

PARENT ACKNOWLEDGEMENT OF VERBAL CONSENT

I, parent/legal guardian, gave verbal permission to the day care program to administer the above indicated medication on

(date)

Parent or Legal Guardian’s Signature:

This is a double-sided form

Updated 11/04

Verbal Medication Consent Form And Log Of Administration - New York State Office Of Children And Family Services Page 2