Medication Request Form 2025

1. Click ‘Get Form’ to open the Medication Request Form in our editor.
2. In Box 1, the parent or guardian must complete all required fields. Check the applicable medication types and provide the child's name, date of birth, medication name, weight, exact dosage, administration times, and sign with the date.
3. Box 2 requires a licensed physician, dentist, or advanced practice nurse to fill out specific instructions for nonprescription medications or modified diets. Ensure they include dosage instructions and possible side effects.
4. In Box 3, child care center staff must document each administration of medication. Record the child's name, medication amount, date and time of dosage, and have the designated person sign off on it.

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