PrescriptionMed



PRESCRIPTION MEDICATION

	I hereby give _____________________________ permission to administer the following prescription medicine to my child. Child's Name: __________________________ Date of Birth: _______________ Name of Medicine: ___________________________ Reason Needed: _____________________________________________________ ____________________________________ __________________ Parent's Signature Date INSTRUCTIONS Prescription is to be given from _______________ to _______________ TIME DOSAGE AMOUNT ________________ _________________ ________________ _________________ ________________ _________________ MEDICATION LOG ======================================================= DATE TIME DOSAGE =======================================================


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