Medication Authorization Form
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1
2Medication Authorization Form
Child’s Name:
Date of Birth/Age:
Name of Medication:
Reason for Medication:
Start Date:
Stop Date:
Times to be given:
Amount to be given:
(*Can NOT be given “as needed”)
Possible Side Effects:
Oral
Topical
Other
Above information consistent with label?
Requires Refrigeration:
yes
no
Special Instructions:
_________________________________
______________________
Parent/Guardian Signature
Date
_______________________________________
Daytime Phone Number
_______________________________________
__________________________
Physician Signature
Date
_______________________________________
Physician Phone Number
Child Care Health Program - February 2004
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Parent category: Business