# Medication Authorization Form

## Patient Information
- **Patient Name:** _________________________
- **Date of Birth:** _________________________
- **School/Daycare:** _________________________

## Medication Information
- **Medication Name:** _________________________
- **Dosage:** _________________________
- **Frequency:** _________________________
- **Route:** ☐ Oral ☐ Topical ☐ Inhaler ☐ Other: _________________________

## Prescriber Information
- **Prescriber Name:** _________________________
- **Phone:** _________________________
- **Date Prescribed:** _________________________

## Administration Instructions
- **Time of Day:** _________________________
- **Special Instructions:** _________________________
- **Storage Requirements:** _________________________

## Side Effects & Monitoring
- **Known Side Effects:** _________________________
- **Monitoring Requirements:** _________________________

## Emergency Information
- **Allergic Reactions:** _________________________
- **Emergency Contact:** _________________________
- **Phone:** _________________________

## Authorization
☐ I authorize the administration of the above medication at school/daycare
☐ I understand the risks and benefits of this medication
☐ I will provide updated medication information as needed
☐ I will notify the school/daycare of any changes

**Parent/Guardian Signature:** _________________________
**Date:** _________________________

**School/Daycare Representative:** _________________________
**Date:** _________________________

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*Rose Pediatrics Care - Medication Authorization Form*