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 _________________________________

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