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:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Medical Release Form
Agree & Sign