Daily Medication Chart - Day Care Connection

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DOCTOR’S LETTER OF INSTRUCTION
Under Toronto Children’s Services Operating Criteria, childcare providers may not administer
non-prescription medications without the written permission from a physician. If you are willing
to provide written consent at this time, please complete the following:
Medication
Dose
Timing
Physician’s Name: (please print) ___________________________________________________
Physician’s Address: (please print) _________________________________________________
Physician’s Phone Number: _______________________________________________________
Physician’s Signature: _________________________________ Date: _____________________

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