Medication Log Template For Child

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Child's Name:
MEDICATION LOG
55 Pa. Code §3270.133; §3280.133; §3290.133
PLEASE PRINT
Medication:
Page_'
~~of~~-
D
Prescription
D
Non-Prescription
Refrigeration Required:
D
YES
D
NO
If Prescription, Prescriber's Name: - - - - - - - - - - - - - - - - - - -
Telephone: - - - - - - - -
Dosage Amount:
Time to Administer:
-~~
a.m.
p.m.
times/day
Dates for Administration:
From _______ To
Date
Dale
Special instructions i.e., symptoms signaling need for administration, medication indications, reasons to hold medication,
contraindications:
I
give permission to administer medication to my child as stated above.
Parent Signature
Date
This information is confidential and may not be shared or .released without the parent's written permission.
CY 862 1.0/04

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