Medication Consent Form - The Magical Years Early Learning Center, Inc. printable pdf download

Medication Consent Form - The Magical Years Early Learning Center, Inc.

Medication Consent Form

For Tylenol, Ibuprofen, Benadryl Etc.

Must be accompanied by a letter from your child’s Physician

Name of child: ______________________________________________________________

Name of medication: _________________________________________________________

Please

one of the following:

Prescription: _____

Oral/Non-Prescription: _____ Diaper Cream:____

Unanticipated Non-Prescription for mild symptoms______

Topical Non-Prescription (applied to open wound/ broken skin)______

My child has previously taken this medication________

My child has not previously taken this medication, but this is an emergency medication and I give permission

for staff to give this medication to my child in accordance with his/her individual health care plan_______

Dosage: ___________________________________________________________________

Date(s) medication to be given: _________________________________________________

Times medication to be given: __________________________________________________

Reasons for medication: _______________________________________________________

Possible side effects: _________________________________________________________

Directions for storage: ________________________________________________________

Name and phone number of the prescribing health care practitioner:

___________________________________________________________________________

Child’s Health Care Practitioner Signature ___________________Date_______________

I, __________________________________________, (parent or guardian) gives permission

(print name)

to authorize educator(s) to administer medication to my child as indicated above.

Parent/Guardian Signature

______________________________ Date_______________

For topical, non-prescription NOT applied to open wound / broken skin (parent signature only)

Medication Consent Form - The Magical Years Early Learning Center, Inc.