Medical Authorization Form
Medicine must be in its original container.
Prescribing Physician's Name/Phone Number *
Your answer
Parent's Name(s) *
Your answer
Child's Name *
Your answer
Medication Name *
Your answer
Dosage Amount *
Your answer
Time to be Given *
Your answer
Date(s) to be Given *
Your answer
Side Effects/Anticipated Reactions *
Your answer
Special Instructions (if applicable)
Your answer
I understand that medicine must be in its original container. If all information is not filled in completely, medication will not be given. I understand that maintenance medical authorization shall be updated as changes occur or at least every three (3) months. *
Required
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