MEDICATION AUTHORIZATION FORM

TO BE COMPLETED BY PARENT

Child’s_Name__________________________________________________________Date of Birth_____/____/______

Program_Name_____Ms._Julie’s_Daycare________________________________Today’s Date_____/____/______

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To administer a prescription medication:

• The medication must be in its 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_giving:_________________________________________________________________________________________________________________________

Start date_____/____/___ End date____/____/____

Dosage:_______________ Times to be given at child care:________AM_______PM

Last dosage was given at_________AM / PM, On date____/____/____

Route: by mouth, skin (location)________, eye (R / L)

Possible_side_effects:_______________________________________________________________________________________________________________________

Special handling/storage Instructions___________________________________________________________

Refrigeration Y/N

Parent/Guardian Signature

___________________________________________________________________

Physician/Nurse_Practitioners_Signature

___________________________________________________________________

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Non-Prescription Medication:

• Parent is required to bring these medications from home.

• Medication must be in an original container, with child’s name on the container.

Medication:________________________________________________________

Health Care Provider_________________________________________________

"For children under 2, list the name of the health care provider who recommended this medication."

Reason_for_giving:_______________________________________________________________________________________________________________________

Start date_____/____/___ End date____/____/____

Dosage:_______________ Times to be given at child care:________AM_______PM

Last dosage was given at_________AM/PM on date____/____/____

Route: by mouth, skin (location)________, eye (R/L)

Possible_side_effects:_______________________________________________________________________________________________________________________

Special handling/storage Instructions___________________________________________________________Refrigeration Y/N

Parent/Guardian Signature __________________________________________________________________

Physician/Nurse_Practitioners_Signature

___________________________________________________________________

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Unused medication: Returned to Parent Y/N or, discarded appropriately (circle one)

By: ________________________________________________ Date _____/_______/_______

*Keep in the child’s file when medication is finished.