I authorize the administration of ____________________ ____________ ,provided in its original container, to ____________________ __________ by the provider.
Child's Current Weight : __________________ Child's Current Age: __________
Purchased on: _________________ Expiry Date: ________________
Administration to Start On: __________ Administration to End On: ___________
Prescribed Dosage to be Received: ____________________ ______
Specific Time(s) to administer for: ____________________ _____________
Specific Symptoms to administer for: ____________________ _____________
Specified Storage of Medication Shall be: ____________________ _________
Stop medication if the following symptoms are observed: ________________
I understand if questions arise about giving/applying the medication, my provider will contact the dispensing pharmacy to clarify issues. I.e. when to give/apply and how often. If an appropriate response can not be obtained, or safety of child is in question, medication will not be administered.
I understand and accept that if problems arise with the giving/applying of the medication I.e. refusal by child to take medication, side effects, or an allergic reaction the child care provider will stop giving or applying the medication and will notify me.
Date Parent's Signature