Medication Consent Form

Name of Child

Name of Medication

Please check one of the following:

Prescription Choice

Prescription

Oral/Non-Prescription

Unanticipated Non-Prescription for Mild Systems

Topical Non-Prescription (applied to open wound/broken skin)

My child has previously taken this medication

My child has not previously taken this medication, but this is an emergency medication and I give permission for staff to give this medication to my child in accordance with his/her individual health care plan.

Dosage

Date(s) medication to be given:

Times medication to be given:

Reasons for medication:

Possible side effects:

Directions for storage:

Name and phone number of the prescribing health care practitioner:

Parent Signature

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For topical, non-prescription NOT applied to open wound / broken skin (parent signature only)