Hennepin County Permission to Administer Medications

Hennepin County Permission to Administer Medications
How many medications do you wish to add?*

12345
Note: This includes diapering products, sunscreen lotions and insect repellents as well as both prescription and non-prescription medications. These products must be administered according to the manufacturer’s instructions unless there are written instructions for their use provided by a licensed physician or dentist). Note: Sunscreen should not be applied to children under 6 months old unless a doctor’s note is given or parent consent (written) is given.
Child Name*

First NameLast Name
Child Date of Birth*

MonthDayYear
Date
Medication 1
Program Name
Medication Name
Medication Dosage
Medication Frequency
Medication time to be administered
Start time

Hour Minutes

AM/PM Option
End time

Hour Minutes

AM/PM Option
Condition for which prescribed
Side effects (if any)
Medication 2
Program Name
Child Name*

First NameLast Name
Medication Name
Medication Dosage
Medication Frequency
Medication time to be administered
Start time

Hour Minutes

AM/PM Option
End time

Hour Minutes

AM/PM Option
Condition for which prescribed
Side effects (if any)
Medication 3
Program Name
Child Name*

First NameLast Name
Medication Name
Medication Dosage
Medication Frequency
Medication time to be administered
Start time

Hour Minutes

AM/PM Option
End time

Hour Minutes

AM/PM Option
Condition for which prescribed
Side effects (if any)
Medication 4
Program Name
Child Name*

First NameLast Name
Medication Name
Medication Dosage
Medication Frequency
Medication time to be administered
Start time

Hour Minutes

AM/PM Option
End time

Hour Minutes

AM/PM Option
Condition for which prescribed
Side effects (if any)
Medication 5
Program Name
Child Name*

First NameLast Name
Medication Name
Medication Dosage
Medication Frequency
Medication time to be administered
Start time

Hour Minutes

AM/PM Option
End time

Hour Minutes

AM/PM Option
Condition for which prescribed
Side effects (if any)
Prescriber Information
Prescription number(s) if applicable
Date of prescription(s) if applicable
Doctor's name if using prescription(s)
Doctor's number
Please enter a valid phone number.
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/Guardian Signature*

Clear
Date of Signature

MonthDayYear
Date
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Hennepin County Permission to Administer Medications

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Prescriber Information

Signatures