Over the counter Medication Administration Request 2024
Any medication -prescription and over the counter -needs to be accompanied with this form
The form needs to be filled out and printed and signed . The medication has to be in the original container, up to date and correctly labelled with name and strength of medication. Please put medication and this med form in a ziplock bag and hand to check-in staff. PLEASEĀ  ONLY PROVIDE NEEDED AMOUNT (not a big bottle of headache remedy, antihistamine, after bite)
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Email *
Name *
Date of Birth
*
MM
/
DD
/
YYYY
Parent /Guardian Name and their phone numbers
*
Physician Name and Phone Number
*
Patient Allergies
*
Name of medication *
Form of medication
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Route of Medication
*
Restrictions
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Dosage and time given-indication when needed. Please type specific Symptoms necessitating the administration of Over-the-counter Medication:

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Storage caution and caution of possible side effect of medication
*
Please sign and date
*
Submit
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