Permission To Administer Medication

Child’s Name:____________________________ Date medication started:_________________________

Name of Medication:_______________________________Dosage:______________________________

Times of day to be administered:__________________________________________________________

Provider’s Name:__________________________

I hereby authorize the above named provider to administer the above named medication in the dosage and times of day as indicated to the above named child.

Signature of Parent/Guardian:______________________________________________

Medication Log

Day Time __Initials Time Initials Time Initials _ Time Initials_ Time Initials

Monday

______________________________________________________________________________________

Tuesday

______________________________________________________________________________________

Wednesday

______________________________________________________________________________________

Thursday

______________________________________________________________________________________

Friday

Medication has been terminated on ____/____/____ Signature of Parent/Guardian_______________________

Permission To Administer Medication

Child’s Name:____________________________ Date medication started:_________________________

Name of Medication:_______________________________Dosage:______________________________

Times of day to be administered:__________________________________________________________

Provider’s Name:__________________________

I hereby authorize the above named provider to administer the above named medication in the dosage and times of day as indicated to the above named child.

Signature of Parent/Guardian:______________________________________________

Medication Log

Day Time __Initials Time Initials Time Initials _ Time Initials_ Time Initials

Monday

______________________________________________________________________________________

Tuesday

______________________________________________________________________________________

Wednesday

______________________________________________________________________________________

Thursday

______________________________________________________________________________________

Friday

Medication has been terminated on ____/____/____ Signature of Parent/Guardian_______________________