Form Ocfs-Ldss-7002 - Written Medication Consent Form (Page 2 of 2) in pdf

OCFS-LDSS-7002 (11/2004)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

WRITTEN MEDICATION CONSENT FORM

PARENT/GUARDIAN MUST COMPLETE THIS SECTION (#19 - #23)

19. If Section #7A is completed, do the instructions indicate a specific time to administer the medication? (For example, did the prescriber

write 12pm?)

Yes

N/A

Write the specific time(s) the day care program is to administer the medication (i.e.: 12pm):

20. I, parent/legal guardian, authorize the day care program to administer the medication as specified in the “Licensed Authorized

Prescriber Section” to

(child’s name)

21. Parent or legal guardian’s name (please print):

22. Date authorized:

23. Parent or legal guardian’s signature:

DAY CARE PROGRAM TO COMPLETE THIS SECTION (#24 - #30)

24. Provider/Facility name:

25. Facility ID number:

26. Facility telephone number:

27. I have verified that #1-#23 and if applicable, #33-#36 are complete. My signature indicates that all information needed to give this

medication has been given to the day care program.

28. Authorized child care provider’s name (please print):

29. Date received from parent:

30. Authorized child care provider’s signature:

ONLY COMPLETE THIS SECTION (#31-#32) IF THE PARENT REQUESTS TO DISCONTINUE THE

MEDICATION PRIOR TO THE DATE INDICATED IN #15

31. I, parent/legal guardian, request that the medication indicated on this consent form be discontinued on

(date)

Once the medication has been discontinued, I understand that if my child requires this medication in the future, a new written medication

consent form must be completed.

32. Parent or Legal Guardian’s Signature:

LICENSED AUTHORIZED PRESCRIBER TO COMPLETE, AS NEEDED (#33 - #36)

33. Describe any additional training, procedures or competencies the day care program staff will need to care for this child.

34. Licensed Authorized Prescriber’s Signature:

35. Since there may be instances where the pharmacy will not fill a new prescription for changes in a prescription related to dose, time or

frequency until the medication from the previous prescription is completely used, please indicate the date by which you expect the

pharmacy to fill the updated order.

DATE:

By completing this section the day care program will follow the written instruction on this form and not follow the pharmacy label until the

new prescription has been filled.

36. Licensed Authorized Prescriber’s Signature:

This is a double-sided form

Updated 11-04

Form Ocfs-Ldss-7002 - Written Medication Consent Form Page 2