Medication Release Form printable pdf download

Medication Release Form

Please Write Clearly

Name of Child: __________________________________________________________________________

Age: _____________

Name of Medication: _________________________________________________________________________________________

Condition Being Treated: ______________________________________________________________________________________

Date(s) Medication is to be Given: _______________________________________________________________________________

Time(s) Medication is to be Given: _______________________________________________________________________________

Dosage / Amount to be Given: __________________________________________________________________________________

Method of Administration (for example, orally, topically, nasally, etc.): ___________________________________________________

Possible Side Effects or Interactions with Other Drugs: _______________________________________________________________

___________________________________________________________________________________________________________

I hereby give my permission for the provider to administer this medication according to the instructions above. I agree that the

provider will not be held liable for any illness or injury resulting from the administration of this medication, and will not be held

responsible for the reimbursement of any medical expenses resulting from such action.

_____________________________________________________________________

______/______/______

Signature of Parent or Guardian

Date

Verbal Authorization: Date & Time: _____________________

Provider’s Signature ____________________________________

Parent’s Signature _____________________________________________________________________________

Medication Administration Record

Date

Time

Dosage

Administered By

Reactions

Administration Errors

____/____/____

This form is provided for technical assistance purposes only. Providers may use this form if they choose, but are not required to use this form.

Medication Permission & Administration Form

DOH/BCCL 8/08

Medication Release Form