CA}t? r|f,AlTlf HETONY AND U^}IINATIOFI F(}RM FMAFOR CNII-DREN, IOUTR AND ADULTS

Dodopcd btlocrn:en C.empinj Arsocilioo, toc-, in consulr:tba vitbTlr Ancri:al Mcdial Arscirtioa rad tbc A.ncri:ra Acrdcoy of P-.ri*'i,cr

This sidc to befillcd in by porents/guordion of minorc,

Child's Name Birth Darc Scx - ABeL-

Pareat or Guardian (or Spousc) Phone

HoneAd&css

Busincss Ad&crs5rali-L A,

Sccood Parett or Guardian or Emcrgcocy Contact:

Home Addres

Busio.:s Addrcs5d- a t{-a-r

If nort ay:il:ble in an cmogsnqf, notify:

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Phone9- ----Ur€.-

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Phone

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Name

AddrcssSlral .- t -

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ADcrlitrHry Fctrlvy Pdrcaioj, crc-lE g Sti-FFcdcflirOrbcr DrqtA.nhar

Opcrations or scrious i:ojurics (dota|

Disabiliry or cbronic or rccurring illncss:

Any spccific acdyftie ro bc cocouraged or limircd by physician's adnics:

Dictary modi ficarions :Curreat mcdicadon (send with ittsttwctionsf.Othcr discascs or dcails of above:Name of dcmisr/onhodontist: Phooe

PtroncName of family physici^n:

Datc of last physical clu[nirurtion:Do you carry family mcdicaVbospiral insurancc? _

Carricr:Su33cstions or healrb relalcd information for o'np pcrrcnnc!:

lf so, indczte:Policy or Group t

(Foc Fcndc): Has rhi< pcrson mtnstruated? - If nor, basslrcbcco rold abour ir? _If so, is hcr ocastural hisrory normal? Spccial Consllcrarion:

bgort-t-Tfil Eor lrfa bc Co-/crcl loc Anodroct'

CryFiabt t963 ba7 Aaxriol C--pirf rsociarioo

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this bc.lt hinor; b ooroct Jo tar u t fctor, ead rlc pcroc hcrciolcer;bca bs p<rmirrbl ro .rlrlr ia e! prc<ribcd rtop siviricr--.tr rr Dorcd-

Erjocylulciabrr I hccUy fw e<rnisi<n ro rtr ocdirrl prr-tood td.qcd by rhc crog dirtrror ro odct X-nyr. rociac tc:rr, rnd

ttcrEEEta fc c/c n; dtild, eld io rhc atnr I czlror bc r:rhcd in eoct!.tfi.t, I b.rBbt glrc ecnisCar ro rhc plyiicbD iclcstcd bt rl|GctrrtD dirrrrc ro lrcrpirdirt. s.curc propcr trrarmcrr for, end ro ordc,biaba erdlc en<s}cth end,ror lurFqr Ja v,/q oy child as nancdebore- Thb forn nrry bt phorocodcd fot usc our of crrnp-

Sfulrrrnt ol pon:or or !uard;t!

C'"^/trftLSi4es

MEDICATION CONSENT FORM

I hereby request and give my consent for fhe Crop nurse or persorrdesigpated by the arlministraltor to sce that my child:

Nane:

receives the nredication pnescn'bed by:

for the period frorn

The medication is to bc furnistrcd by mc in the original container and is to belabeled with md given in &e followingrxurlcr:

l. Name of medisino md pmescritrion number:2. Route of administrdion (by mcfi, e*c.):3. Amount to be giru4- Time of day to bc taken-5- Expected duration of tre4rned:6. Physician's nas€ (must be on label):7. RcaSOnfm nu 'lic+,tbn:8- Reactisr to illcdicdi{n d s at}ergi€s:

to

Signature of Parent sr Guirrdien

***Pltns€ cheek ofr the following: *rrTylenol - OK Yes NoMo{rin - OK Yes No

T)ai€