MEDICATION AUTHORIZATION FORM

MEDICATION AUTHORIZATION FORM

TO BE COMPLETED BY PARENT

Child’s_Name__________________________________________________________Date of Birth_____/____/______

Program_Name_____= Ms._Julie’s_Daycare________________________________Today&= #8217;s Date_____/____/______

****************= ***************************************************************************= ***

To administer a prescription medication:

• The medication must be in its original container, with a legib= le 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 or= der

• Parent/Guardian is to give as many doses as possible at home.<= o:p>

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)<= o:p>

Possible_side_effects:__________________________________________________________________= ________________________= _____________________________

Special handling/storage Instructions___________________________________________________________

Refrigeration Y/= N

Parent/Guardian Signature

________________= ___________________________________________________

Physician/Nurse<= /span>_Practitioners_Signature

________________= ___________________________________________________

****************= ***************************************************************************= *

Non-Prescription Medication:

• Parent is required to bring these medications from home.<= /o:p>

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

Medication:_______________________________= _________________________

Health Care Provider__________________________________= _______________

"For child= ren 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

________________= ___________________________________________________

****************= ***************************************************************************= *

Unused medicatio= n: Returned to Parent Y/N or, discarded appropriately (circle one)<= /span>

By: ________________________________________________ Date _____/_______/_______=

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

<= o:p>