Administration Of Medication Consent Form printable pdf download

Administration Of Medication Consent Form

ADMINISTRATION OF MEDICATION CONSENT FORM

’

CHILD

S NAME

’

PHYSICIAN

S NAME

PHONE

PHARMACY NAME

PHONE

MEDICATION

PRESCRIPTION

DOSAGE OF MEDICATION

HAS THIS MEDICATION BEEN ADMINISTERED TO THIS CHILD PREVIOUSLY

YES

IF NO

HAS CHILD RECEIVED MEDICATION FOR

HRS PRIOR TO

YES

RETURNING TO THE CHILD CARE PROGRAM

TIMES TO BE GIVEN BY PARENT

TIMES TO BE GIVEN BY CARE PROVIDER

ANY POSSIBLE SIDE EFFECTS THAT YOU HAVE BEEN MADE AWARE OF BY THE PHYSICIAN OR PHARMACY

I hereby give permission and authorize _____________________________________ to

administer the medication in the dosage as stated above. This dosage is consistent with the

recommendations of the Physician and/or drug manufacturer. I accept the responsibility of

supplying the current correct medication in its original container, and I agree to submit a new

consent form if there is any change in the medication to be administered.

Signature of Parent/Guardian

Date

Phone

CAREGIVER’S ADMINISTRATION RECORD:

DATE

TIME GIVEN

AMOUNT GIVEN

ADMINISTERED BY

SECTION 3 – JUNE 2004

Administration Of Medication Consent Form