Prescription Medication Form

ALL prescription medications must be in the original containers with the labels undamaged and readable.

Child’s Full Name:________________________________________

Date:___________________

Name of Medication:______________________________________

Dosage:____________________________

Time(s) of Dosage(s):_____________________________________

Special Instructions:_____________________________________

Start Date:_________________ End Date:___________________

Possible Side Effects: __________________________________________________________________________________________________________

Rx Number:_____________________________

Name of Pharmacy:__________________________________

Pharmacy Address:______________________________________

Pharmacy Phone:____________________

Name/Phone of Prescribing Physician: ______________________________________________

I release Jaymi Greenlee from any liability from administering this medication.

____________________________ ____________________

(parent signature) (date)