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Permission To Administer Medication

The document provides a form for parents to give permission for child care staff to administer prescription medication to their child according to a doctor's orders. It includes spaces for the child and parent's name, medication name and prescription number, and the parent's signature. A separate form is included for recording details of medication administration by staff such as date, time, dosage, and signature.

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Kaify Jamil
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181 views2 pages

Permission To Administer Medication

The document provides a form for parents to give permission for child care staff to administer prescription medication to their child according to a doctor's orders. It includes spaces for the child and parent's name, medication name and prescription number, and the parent's signature. A separate form is included for recording details of medication administration by staff such as date, time, dosage, and signature.

Uploaded by

Kaify Jamil
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PERMISSION TO ADMINISTER MEDICATION

DATE: _________________________

I hereby give my permission to the staff of _____________________________________ to administer:

___________________________________ ____________________________________
Name of Medication Prescription Number

to my child _________________________________ according to the Doctor’s orders and instructions.

(These will be on the vial or bottle for prescription drugs and on the “Request for Administration of Non-
Prescription Medication at Child Care Centre form for non-prescription drugs).

______________________________
Signature of Parent or Guardian

MEDICATION RECORD

NAME OF CHILD: ____________________________ PHYSICIAN: _____________________________

NAME OF MEDICATION: ______________________________________

DATE COMMENCED: ________/________/__________ DATE STOPPED: _______/______/________

DATE TIME DOSAGE COMMENTS STAFF SIGNATURE

NOTE: One form for each prescription or refill.


Completed form filed in child’s file.
H516-92/01
REQUEST FOR ADMINISTRATION OF
NON-PRESCRIPTION MEDICATION AT CHILD CARE FACILITY

A. TO BE COMPLETED BY PARENT OR GUARDIAN:

NAME OF CHILD: _______________________________ BIRTHDATE: _______/______/______

NAME OR GUARDIAN: ____________________________________________________________

PHONE: HOME: ________________________ BUSINESS: _____________________________

PHYSICIAN: _____________________________ PHONE: _______________________________

B. TO BE COMPLETED BY PHYSICIAN

CONDITION WHICH MAKES MEDICATION NECESSARY:

NAME OF MEDICATION: ______________________________________

DOSAGE: Pills __________ Drops __________ Tsp. __________ Ounces __________ Mls. ________

TIME: A.M. ________ P.M. ________ DATE TO START: _____/_____/______

TO BE GIVEN WITH: _______________ DATE TO GIVE LAST DOSE: ____/______/______


(Water, Milk, Juice)

ADDITIONAL COMMENTS: (Possible Reactions, Consequences of Missing Medication, etc.)

DATE: _____/_____/_____ SIGNED: _____________________

PHONE NO: __________________

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