Medication Consent Form

Location Selection:(Required)

Commonwealth of Massachusetts
Department of Early Education and Care

MEDICATION CONSENT FORM 606 CMR 7.11(2)(b)

Name of child:(Required)

Name of medication:(Required)

Please select one of the following:(Required)

Prescription

Oral/Non-Prescription

Unanticipated Non-Prescription for mild symptoms

Topical Non-Prescription (applied to open wound/ broken skin)

Dosage:(Required)

Date(s) medication to be given:(Required)

Times medication to be given:(Required)

Reasons for medication:(Required)

Possible side effects:(Required)

Directions for storage:(Required)

Name and phone number of the prescribing health care practitioner:(Required)

Please get your Child’s Health Care Practitioner Signature and Date and attach it to the form below.

File Attachment

Accepted file types: jpg, jpeg, pdf, png, doc, docx, Max. file size: 30 MB.

Parent/Guardian Name:(Required)

Parent/Guardian Signature(Required)

Date(Required)

For topical, non-prescription NOT applied to open wound / broken skin (parent signature only)