Administration of medication form
Child's Full Name
Date of Prescription
Start Date _____________________________________________
End Date _______________________________________________
Doctor Prescribe meds name ______________________________
Name of Prescription______________________________________
Time to give meds ________________________________________
Amount of Meds to be given by caregiver _____________________
Time Am____________________Pm ______________________
Medication Release
I __________________________________-give Kristina Steiner permission to
administer the above meds as prescribed above to my child
________________________________________.
I understand that Kristina Steiner will not be held responsible for any allergic reactions
or any other complications resulting from the administration of the above medication,
given according to the directions stated above.
Parents Signature___________________________________
Date______________________
Office use only
Is the prescribed medication in the original container,clearly marked, and dosage
?____________________
Administration Record
Date ____________________________
time ____________________________
Amount __________________________
Date _____________________________
Time ____________________________
Amount____________________________
Date ______________________________
time ______________________________
Amount____________________________
Date _______________________________
Time ______________________________
Amount ___________________________
Date ________________________________
Time ________________________________
Amount________________________________
Date of Prescription
Start Date _____________________________________________
End Date _______________________________________________
Doctor Prescribe meds name ______________________________
Name of Prescription______________________________________
Time to give meds ________________________________________
Amount of Meds to be given by caregiver _____________________
Time Am____________________Pm ______________________
Medication Release
I __________________________________-give Kristina Steiner permission to
administer the above meds as prescribed above to my child
________________________________________.
I understand that Kristina Steiner will not be held responsible for any allergic reactions
or any other complications resulting from the administration of the above medication,
given according to the directions stated above.
Parents Signature___________________________________
Date______________________
Office use only
Is the prescribed medication in the original container,clearly marked, and dosage
?____________________
Administration Record
Date ____________________________
time ____________________________
Amount __________________________
Date _____________________________
Time ____________________________
Amount____________________________
Date ______________________________
time ______________________________
Amount____________________________
Date _______________________________
Time ______________________________
Amount ___________________________
Date ________________________________
Time ________________________________
Amount________________________________