Daily Medication Administration Form Harbor Haven 470 Prospect

Daily Medication Administration Form
Harbor Haven 470 Prospect Ave, Suite 203B, West Orange, NJ 07052
Phone (908) 964-5411
Fax (908) 964-0511
Child’s Name: ______________________________ Date of Birth: ___________________________
Medication Name
(List only meds to be
given at Harbor
Haven)
Prescribing
Physician’s Name
& Signature
Dosage
Number of
Tablets/Tsp
Administration
Time
Reason
Possible
Side
Effects
_______________
___________
__________
_______________
____________
______________ ______________
_______________
___________
__________
_______________
____________
______________ ______________
_______________
___________
__________
_______________
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______________ ______________
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___________
__________
_______________
____________
______________ ______________
Physician’s
Telephone Number
Please provide the Harbor Haven nurse with a least a two week supply of your child’s medication(s) prior to the start of the program. Please make
sure the medication is in its original prescription bottle with the same dosage directions as above.
You may bring the medication in when you come for orientation on June 24 (for weeks 1-4) or July 18 (for a July 25 start date). If you are not able
to attend the orientation, please contact us so that we can arrange another time for you to bring in your child’s medication. Please pre-cut any
tablets which are not given whole. Thank you for your co-operation.
I hereby give permission for the nurse at Harbor Haven to administer the above named medications.
__________________________________
Signature of Parent/Guardian
________________
Date
I hereby give my permission for the following over-the-counter medications to be administered, if needed to my child at Harbor Haven.
Tylenol (Headache)
Pepto Bismol (Upset Stomach)
Calamine Lotion (Itching).
Please list any other: _________________________________________________________
__________________________________
________________
Signature of Parent/Guardian
Date
This form must be complete, including the Physician’s signature; otherwise the nurse is legally not allowed to dispense any medication.
Additionally, each medication to be given must be in its own prescription labeled bottle that matches these directions or it cannot be given.