Medication Log Template
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1
2MEDICATION LOG
55 Pa. Code §3270.133; §3280.133; §3290.133
PLEASE PRINT
Child’s Name: __________________________________ Medication: ___________________________________
Prescription
Non-Prescription
Refrigeration Required:
YES
NO
If Prescription, Prescriber’s Name: ___________________________________ Telephone: __________________
Dosage Amount: _______________
Time to Administer: __________a.m. __________p.m. _________times/day
Dates for Administration:
From ____________ To ______________
Date
Date
Special instructions i.e., symptoms signaling need for administration, medication indications, reasons to hold
medication, contraindications:
___________________________________________________________________________________________
__________________________________________________________________________________________
I give permission to administer medication to my child as stated above.
_____________________________________
___________________
Parent Signature
Date
MEDICATION LOG
55 Pa. Code §3270.133; §3280.133; §3290.133
PLEASE PRINT
Child’s Name: __________________________________ Medication: ___________________________________
Prescription
Non-Prescription
Refrigeration Required:
YES
NO
If Prescription, Prescriber’s Name: ___________________________________ Telephone: __________________
Dosage Amount: _______________
Time to Administer: __________a.m. __________p.m. _________times/day
Dates for Administration:
From ____________ To ______________
Date
Date
Special instructions i.e., symptoms signaling need for administration, medication indications, reasons to hold
medication, contraindications:
___________________________________________________________________________________________
__________________________________________________________________________________________
I give permission to administer medication to my child as stated above.
_____________________________________
___________________
Parent Signature
Date
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