MEDICINE CONSENT FORM

BROWN’S FAMILY DAYCARE, INC.

License No.: 283003772

MEDICINE CONSENT FORM

Name of child _________________________________ Age ________________

Medicine for ______________________________________________________ (reason(s) for taking medication).

1.)    Name of medication _____________________________dosage ___________

To be given every________________ (frequency) by _______________________  (body location and method of use) on the date(s) of: __________________________. The last dose was administered today at:  _________________________________

2.)    Name of medication _____________________________dosage ___________

To be given every________________ (frequency) by _______________________  (body location and method of use) on the date(s) of: __________________________. The last dose was administered today at:  _________________________________

Side effects to watch out for may include: (list all possible side effects)

This medicine was prescribe by:______________________________________________(name of practitioner)

Address ______________ ___________________________________________

City and zip code _________________________Tel. No._____________________

Signature of parent/guardian ___________________________________________

Date _________________

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