Krebss Home Child Care

MEDICATION ADMINISTRATION AUTHORIZATION

Childs Name: ___________________________________ Birth Date: __________________________

Medication to be administered by Angela Krebss, of Krebss Home Child Care .
Medication name: ____________________________________________________________________________
For the treatment of: __________________________________________________________________________
Prescribed by: ___________________________________
Start date: _______________________________
How many days has the child been on this medication?

Phone# ________________________________

End date: __________________________________

_____________

Observations/side effects: ______________________________________________________________________

___________________________________________________________________________________________
Times to be given:

_______________

_______________

_______________

_____________

Dosage: ____________________________________________________________________________________
Special instructions: __________________________________________________________________________
__________________________________________________________________________________________

All medications must be in the original container.

Parent/Caregiver Signature: ____________________________________________________________

Date: ___________________