Medication Form

Medication Form

(one medication per sheet)
Child’s Name
Name of Medication
Dosage on Label
Beginning Date

MonthDayYear
Date
Ending Date

MonthDayYear
Date
Reason for Medicine
Route of Medicine:

oralearseyesnosetopicalinhalationOther
Special Instructions
Refrigeration Required:

YesNo
Prescription (must have prescription label on file):

YesNo
Over-the-counter(Must have original packaging, and must have correct dosage on label for age/weight):

YesNo (If correct dosage is not on packaging, must have dr. authorization for dosage amt)
I blanks (parent/guardian name), give permission for Childcare Discovery Center to administer the medication as listed above, and to
contact the listed physician/pharmacy if questions arise.
Signature
Date

MonthDayYear
Date
Month blanks(If medicine is ongoing, must have a new medicine form each month).

Date: