Medication Authorization/Modification Form

Medication Authorization/Modification Form

Select One:
Effective Date:
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.