Medication Log
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1
2MEDICATION LOG
CHILD'S NAME: ___________________________________
D.O.B.: ________________
ALLERGIES: ______________________________________
PARENT'S/GUARDIAN'S NAME: ________________________________
DR: _____________________________ TELEPHONE: ___________________
MONTH:
__________________________________
TIME
MEDICATION INFO
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DRUG:
DOSAGE:
ROUTE:
REASON:
DATE START:
DATE END:
SP. DIR.:
I, the parent or guardian of the above child give permission for the above medication to be administered.
Signature
Date
TIME
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DRUG:
DOSAGE:
ROUTE:
REASON:
DATE START:
DATE END:
SP. DIR.:
I, the parent or guardian of the above child give permission for the above medication to be administered.
Signature
Date
TIME
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DRUG:
DOSAGE:
ROUTE:
REASON:
DATE START:
DATE END:
SP. DIR.:
I, the parent or guardian of the above child give permission for the above medication to be administered.
Signature
Date
OCCL Medication Log, version 2005
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