General Medical Authorization
Medical Authorization Form - Cosmopolitan Kids
Child’s Name: *
Your answer
Date of Birth/Age: *
Your answer
Name of Medication: *
Your answer
Reason for Medication: *
Your answer
Start Date
MM
/
DD
/
YYYY
Stop Date
MM
/
DD
/
YYYY
Times to be given: *Can NOT be given "as needed" *
Your answer
Amount to be given: *
Your answer
Possible Side effects:
Your answer
Method of Treatment *
Is the information provided consistent with the label? *
Requires Refrigeration? *
Special Instructions
Your answer
Electronic Signature Agreement. By entering your name below; you are signing this Agreement electronically. You consent that the information submitted are to the best of your knowledge as the parent/legal guardian of said child. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. *
Required
Please Entire your Full Name (First and Last) to Sign this Agreement Electronically *
Your answer
Date *
MM
/
DD
/
YYYY
Daytime Phone Number
Your answer
Submit
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