Foster Care Manual: Physician's Written Instruction
This form is to be filled out and signed by the Doctor and the Biological Parent. This form gives permission to administer any medicines or medical treatments to the child. A prescription is not enough.
Physician’s Written Instruction Form
Host Home Child:____________________________
Medication (Generic / Brand):________________________
Dosage to be given per administration:_________________
Number & Time of Administration per day:_______________
Ending date of Administration, if applicable:_______________
Possible Side Effects:___________________________
____________________________________________
______________________________________________
Instructions in the event of a serious reaction:________
______________________________________________
______________________________________________
Emergency Phone Number:________________________
Special Instructions:_____________________________
______________________________________________
Signature of Physician____________________
Signature of Host Home Youth____________________
Signature of Biological Parent____________________
Signature of Agency having Custody_____________________
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