This form is for over-the-counter
as well as prescription medications. It indicates that permission is given by parent and physician or other authorized prescriber
(physician, dentist, advanced practice registered nurse, physician's assistant, optometrist, podiatrist) for the following child
to self-administer the following medications
Physician's signature:___________________________ Date :____________
Physician's Name : ________________________________ Address: _____________________________________________ Phone:_________________
Parent's signature:_____________________________ Date: __________
Child's Name_______________________ D.O.B._________ Parent's Name____________________ Address___________________________ Phone: ____________
Relevant side effects and Controlled allergies or interactions
SEE OTHER SIDE .
The following is a list of medications that we stock that our nurse is allowed to give to your child (because they are listed on our standing orders from our doctor). Please review the list and let us know if your child is allergic to any of these medications or if you do not want your daughter to have them for any other reason.
(i.e. Tylenol), ibuprofen
(i.e. Motrin), benzocaine anesthetic lozenges
(i.e. Cepacol lozenges), cough drops,
antibiotic ointment, povidone-iodine scrub, hydrogen peroxide, epsom salts
(for soaking out splinters, etc.) hydrocortisone cream,
topical analgesic containing benzocaine
(for itching or sunburn), diphenhydramine (i.e. Benadryl), antacid tablets, bismuth
(i.e. Pepto-Bismol), pseudoephedrine
(i.e. Sudafed), anti-fungal cream
(for athletes foot), auro-dry
(for swimmers ear), Loratadine
My daughter can have any of the medications listed. signature _______________________________
My daughter can have any of the medications listed except: __________________________________
Please list ALL allergies,
whether they are seasonal, environmental, to animals, food or medications.
If the nurse is not here for any reason (day off, sickness, emergency) then we have medication and first aid trained staff that can administer medication to your child, but only if you bring the medication, with your child's name on it, and list it on the reverse of this form, with accompanying directions, and if the form is signed by you and your doctor. Please think about which medications you would bring and list on the form. (If your daughter had a headache, rash or bug bite, stomachache or upset stomach, sore throat, menstrual cramps etc. when the nurse is not here) Please also list any prescription medications on the form. All medications, prescription and non-prescription must be in the original container, and with your daughter's name on it. Prescriptions, including inhalers
, must have the pharmacy label with your daughter's name, so keep the original box for the inhaler with the prescription on it.
SEE OTHER SIDE .
PATIENT INFO MEDICAL OUTPATIENT CT QUESTIONNAIRE NEUROSCIENCE IMAGING CENTER Have you ever been diagnosed with any of the following?* If you are a Diabetic, please indicate if you take any of the following: ( GLUCOPHAGE / GLUCOVANCE / METAFORMIN / Are you allergic to any medicines that you are aware of? ADVANDAMET / METAGLIP) Yes_________ No_________ What__________________
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