Medications and Medical Information

I authorize administering the following prescription and non-perscription medications:

1. Name of Medication:
   Purpose:
   Dosage and time given:
   How given:
   Side effects:
   Prescribed by Dr.
   Phone:
2. Name of Medication:
   Purpose:
   Dosage and time given:
   How given:
   Side effects:
   Prescribed by Dr.
   Phone:
3. Name of Medication:
   Purpose:
   Dosage and time given:
   How given:
   Side effects:
   Prescribed by Dr.
   Phone:
4. Name of Medication:
   Purpose:
   Dosage and time given:
   How given:
   Side effects:
   Prescribed by Dr.
   Phone:
   

To be given to ______________________ (family member's name)
by __________________________________________ (caregiver)
____________________________________________ (your signature)
______________________ (date)