Order Number AUTHORIZATION FOR DISPENSING MEDICATION PARENT’S AUTHORIZATION Name of Child to Receive Medicine * Name of Medication * Prescribing Physician * Dosage * Prescription No. When to Give * Expiration Date * Continue Medication Until (date) * NOTE: Medication must be in its original container and labeled with your child’s name and the date medication is left at the facility. Medication can only be administered in amounts according to the label directions. Signature-Parent or Guardian * Date * Disposition of Left-over Medication Returned to Child’s Parent/Guardian Thrown Away Date
