Fillable Printable Medication Consent Form - Arizona

Medication Consent Form - Arizona

Arizona Department of Health Services

Bureau of Child Care Licensing

MEDICATION CONSENT FORM

First & Last Name of CHILD:

Type/Name of Medication:

Prescription #:

Dosage:

Route (method)*:

Start date:

End Date:

Times & frequency:

REASON:

I give permission for the administration of the medication, according to the instructions listed, to the

child listed above.

Date of authorization:

Signature (parent/guardian ):

POSSIBLE SIDE EFFECTS TO WATCH FOR WITH THIS MEDICATION:

* Injections: Attach health care provider’s written authorization.

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FOR STAFF REVIEW PRIOR TO ADMINISTERING MEDICATION:

YES NO

Is the medication consent form complete?

 

Is the original prescription label on the medication container or prepackaged and labeled

for use by manufacturer?

 

Is the full name of the child on the container?

 

Is the prescription or over-the-counter medication current?

 

Is the dose, name of drug, frequen cy of administration given on label consistent with instructions

above?

 

Staff initials:__________

Please use the second page to document administration of the medication.

G:\Forms\Medication authorization.doc (8/11) CCL form - 302

Name of Child:

DATE

NAME OF MEDICATION

RX#

DOSE

TIME

FULL SIGNATURE of AUTHORIZED

STAFF PERSON

G:\Forms\Medication authorization.doc (8/11) CCL form - 302