MEDICATION  AUTHORIZATION FORM

 

 

Patti’s Pre-School & Childcare 6917 Prism St. SE, Lacey, WA, 360-402-9793, pattischildcarepreschool@gmail.com

(good for 1 month from today’s date fill out as needed)

 

CHILD’S NAME____________________________________________ TODAY’S DATE________________________

 

MEDICATION________________­­­_______  DR’S. NAME ___________________PRESCRIPTION NUMBER _______

 

BEGINNING DATE__________________________________ENDING DATE_________________________________

 

TIME’S TO BE GIVEN________________________DOSAGE_____________FREQUENCY_____________________

 

INSTRUCTIONS___________________________________________________________________________________

 

I AUTHORIZE MY CHILDCARE PROVIDER, PATTI JULAGAY, TO ADMINISTER THE ABOVE MEDICATIONS ACCORDING TO THE INSTRUCTIONS LISTED ON THE BOTTLE.

 

__________________________________________________________________________________________________SIGNATURE OF PARENT                                                                            DATE

 

MEDICATION                         DOSAGE                     TIME GIVEN                            PROVIDER SIGNATURE