WP E-Signature by Approve Me - Sign Documents Using WordPress -

Medical Release Form

Name of Child: Age:

Name of Medication:

Condition Being Treated:

Date(s) Medication is to be Given: Monday Tuesday Wednesday Thursday Friday Saturday

Time(s) Medication is to be Given:

Method of Administration (for example, orally, topically, nasally, etc.):

Possible Side Effects or Interactions with Other Drugs:

I hereby give my permission for the provider to administer this medication according to the instructions above. I agree that the provider will not be held liable for any illness or injury resulting from the administration of this medication, and will not be held responsible for the reimbursement of any medical expenses resulting from such action.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

March 30, 2018 12:26 pm MST

Medical Release Form Uploaded by Ty Singleton - ty.depotdaycare@gmail.com IP 24.10.233.218