Medication Authorization Form
Medication Information
*
Rows
Yes
Medication is in Original Container
Date
*
-
Month
-
Day
Year
Child's Name
*
First Name
Last Name
Name of Medication
*
Duration of Medication
*
Start Date
End Date
Dosage Amount
*
According to Label
Time to Administer
*
Expiration Date
*
Side Effects/Anticipated Reactions:
*
Symptoms to watch for leading to administering the medication:
*
Special Instructions/Circumstances for administering medication:
*
When was the exact time and date of the last two doses administered?
*
Dose #1
Dose #2
Signature
*
Parent Name
*
Submit
Should be Empty: