Authorization for Dispensing Medication
Name of Child to receive medication
*
First Name
Last Name
Name of the Medication
*
Prescribing Physician
Prescription No.
Expiration Date
Dosage
*
When to give
*
Continue Medicine Until (date)
*
Note: medication must be in its original container and labeled with your child's name and the date medication is left at the facility. Medication can only be administered in amounts according to the label directions.
Parent/Legal Guardian Name
*
First Name
Last Name
Signature - Parent or Legal Guardian
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Caregiver's Record of Administering Medication
(To be filled out by caregivers)
1. Child's name
Name of Medication
Date given
Time given
Amount given
Full name of caregiver or employee
Disposition of Left-over Medication
Return to Child's parent/guardian
Thrown away
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
2. Child's name
Name of Medication
Date given
Time given
Amount given
Full name of caregiver or employee
Disposition of Left-over Medication
Return to Child's parent/guardian
Thrown away
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
3. Child's name
Name of Medication
Date given
Time given
Amount given
Full name of caregiver or employee
Disposition of Left-over Medication
Return to Child's parent/guardian
Thrown away
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Should be Empty: