Foster Care Manual: Discontinued Medication

This form is filled out when you discontinue medicine or other treatment. It is signed by the doctor and the biological parent.

Discontinued Medication Form

Host Home Child:_____________________________

Medication:__________________________________

Type of Medication (liquid, tablet, etc.):____________

Dosage given per administration:________________

Number & time of administration:_________________

Date discontinued:____________________________

Signature of Physician_________________________

Signature of Host Home Youth___________________

Signature of Biological Parent____________________

Signature of Agency having custody_______________