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Otc medication self-administration authorization form for minors

PARENT APPROVAL FORM. RELEASE FOR OVER-THE-COUNTER DRUGS. (Required form for minors.) APPLICANT NAME: _______________________________________ The medications listed below are over-the-counter (OTC) medications carried by the ships medical office. Please check the boxes to confirm that they may be given as indicated. Triple Antibiotic Ointment as needed for minor wounds …………………………………………….………. Acetaminophen 500 mg 1 tablet every 4 hours as needed for pain/fever……………………….…….…. Aspirin 325 mg 1 or 2 tablets every 4 hours as needed for pain/fever…………………………….…….… Ibuprofen 200 mg 1 or 2 tablets every 6 hours as needed for pain/fever……………………………….…. Antacid Tablets 1 or 2 tablets every 4 hours as needed for heartburn/indigestion……………………… Hydrocortisone Cream as needed for skin irritation……………………………………………………….…. Calamine Lotion/Clear Anti-itch Lotion as needed for itch relief………………………………………….… Icy/Hot – Menthol 2.5% as needed for muscle aches……………………………………………………….…. Cough Drops as needed for cough…………………………………………………………………………….…. Benadryl 1 or 2 tablets as needed for allergic reaction ………………………………………………………. Claritin 1 tablet daily as needed for allergy symptoms………………………………………………………. Sudafed PE Sinus + Allergy - Chlorpheniramine Maleate 4 mg, Phenylephrine HCL 10 mg as needed for congestion…………………………………………………………………………………………. Sudafed PE – Phenylephrine HCL 10 mg as needed for congestion…………………………………….…. Sudafed PE Cold & Cough – Acetaminophen 325 mg, Destromethorphan HBr 10 mg, Guaifenesin 100 mg, Phenylephrine HCI 5 mg as needed for congestion/cough…………………………………. Sudafed PE Severe Cold – Acetaminophen 325 mg, Dextromethorphan HCI 12.5 mg, Phenylephrine HCL 5 mg as needed for cough………………………………………………………………………………. Dayquil – Acetaminophen 500 mg, Dextromethorphan HBR 10 mg, Phenylephrine HCL 5 mg as needed for cough………………………………………………………………………………………………. Nyquil – Acetaminophen 500 mg, Dextromethorphan HBR 15 mg, Doxylamine Succinate 6.25 mg as needed for cough………………………………………………………………………………………………. Theraflu – Acetaminophen 650 mg, Dextromethorphan HBR 20 mg, Phenylephrine HCL 10 mg as needed for cough/congestion…………………………………………………………………….…………. Mucinex – Guaifenesin 600 mg as needed for cough/congestion………………………………………….
I give my consent to the administration of over-the-counter (OTC) medication to my minor child as indicated above. _______________________________________________________________ Parent Signature

Source: http://www.flagshipniagara.org/wp-content/uploads/2013/11/10-OTC-Medication-Self-Administration-Authorization-Form-for-Minors.pdf

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