DKZ 1 and DKZ 4 Medication Authorization Form State of Montana Licensing

Medication Authorization Form
Child Name

First NameLast Name
DOB

MonthDayYear
Date
Type Name of School
Today's Date

MonthDayYear
Date
To administer a prescription medication: • The medication must be in it’s original container, with a legible label from the pharmacy indicating the child’s name, date, name of medicine, dosage, and time, number of days medication is to be given, and expiration date of medication, doctor’s/nurse practitioners name, pharmacy name and telephone number • Samples must be accompanied by a doctor’s written prescription • Medications are to be given only to the child indicated on the label (twins and siblings can not share.) • A separate authorization is required for each medication and each episode of illness • Label constitutes the physicians/nurse practitioner’s order • Parent/Guardian is to give as many doses as possible at home. Medication:
Reason for Medication
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Dosage
Time to be given AM
Time to be given PM
First Dose was Given at
AMPM
Date Medicine was given

MonthDayYear
Date
Where is Medicine taken (mouth, arm eye etc.)
Possible Side Effects
Special Handling Storage Instructions
Refrigeration

YesNo
Parent Signature Required

Clear
Non-Prescription Medicine Parent is required to bring from home. Medication must be in original container, with child's name on container and not expired. Name of Medication:
Health Care Provider
Reason for Medication
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Dosage
Time to be Given AM
Time to be given PM
First Dose was Given at
AMPM
Date first dose was given

MonthDayYear
Date
Location medication was given (mouth, eye, arm etc)
Possible Side Effects
Special Handling Instructions
Refrigeration

YesNo
Signature

Clear
Should be Empty: