"Over The Counter" Medication Release Form


Childīs Name: _________________________________________________

I, __________________________ (parentīs name) give permission for my caregiver, _____________________ (name of caregiver) to administer the following "over the counter medication" to my child whom is named above. I understand that when medication is given according to instructions, I will not hold my provider liable for any reactions or complications that may follow as a result of my child receiving this medication.

Signature of Parent: _______________________________________________

To be filled out completely:
Name of Medicine: _________________________________________________
Reason for Needing Medicine: ________________________________________
Date to start: __________________ Date to finish: ______________________
(please note that I will not administer medication for more than 10 consecutive days).

Acceptable to be administered under these circumstances_______________________
Amount to be administered per dose: _______________________________________
(Please make sure dosage and unit of measure is accurate).

My child has had this medicine before: Yes / No

They had a reaction to this medicine: Yes / No If yes, please give details of reaction:
__________________________________________________________________________


Office Use Only: (to be kept in childīs file)
Medicine must be kept in original container.
Bottle must be labeled with childīs name.