Oral Medication List printable pdf download

Oral Medication List

Instructions: Please fill out this form completely. In order to ensure all paperwork is uniform for each traveler, we do

not accept other types of medication sheets.

Name of Traveler: _____________________________________________________________________

Name and Date of Trip: _________________________________________________________________

Traveler's Home Time Zone*: ____________________

***If traveler does not take any prescribed oral medications, please check here _____

Put an X in the box for when med. should be given**

Special Instructions (e.g. take

Oral Medications and # of

Mg per

Reason for Medication

Frequency

10a

12p

10p

w/ food, alternate medication

pills per dose***

pill

time, etc...)

* Please use traveler’s home time zone for Medication times, we will adjust them for the destination as needed.

** If your medication time is not listed, either check the closest time or write time to be given in the “special instructions” box.

*** If more space is required please make a copy of this form.

Oral Medication List