Medication Consent Form - Arizona
Arizona Department of Health Services
Bureau of Child Care Licensing
MEDICATION CONSENT FORM
First & Last Name of CHILD:
Type/Name of Medication:
Prescription #:
Dosage:
Route (method)*:
Start date:
End Date:
Times & frequency:
REASON:
I give permission for the administration of the medication, according to the instructions listed, to the
child listed above.
Date of authorization:
Signature (parent/guardi an):
POSSIBLE SIDE EFFECTS TO WATCH FOR WITH THIS MEDI CATION:
* Injections: Attach health care provider’s written authorization.
******************************************
FOR STAFF REVIEW PRIOR TO ADMINISTERING MEDICATION:
YES NO
Is the medication consent form complete?
Is the original prescription label on the medication container or prepackaged and labeled
for use by manufacturer?
Is the full name of the child on the container?
Is the prescription or over-the-counter medication current?
Is the dose, name of drug, frequency of administration giv en on label consistent with instructions
above?
Staff initials:__________
Please use the second page to document administration of the medication.
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