Medication Authorization/Modification Form

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Medication Authorization

Medication Modification

Medication Di:scontinuation

Effective Date:

Child's Name:

Medication Name:

Dosage Amount:

Time to be Given:

Date(s) to be Given:

Side Effects/Anticipated Reactions:

Special Instructions/Circumstances for Administrating "as needed" medication:

Parent's Signature

Date

Please note the following requirements, if not followed, will result in medication not given.

Medication MUST be in its original container.
Medication must bear a printed label clearly stating the name of the child to whom the medication has been, prescribed.
All information above MUST be completed.
Medication Authorization/Modification Form to be updated, by parents, as changes occur or at least every three months.

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