Medicines Needed at School or Child Care

 

Child's name ____________________________________________________ 

Diagnosis _______________________________________________________ 

Medicine name ___________________________________________________  

Dosage __________________________________________________________

Potential side effects _______________________________________________


When to give medicine at school or day care: 

_________________________________________________________________ 

_________________________________________________________________ 

Thank you.  Please call if you have any questions.  


Physician's name ________________________________________________

Physician's signature _________________________ Date ____________

Physician's phone number _________________________________