Over-the-Counter Medication Consent Form
Student/Recipient Information
Full Name
Date of Birth
Grade/Class
Parent/Guardian Name
Contact Number
Medication Information
Medication Name
Dosage
Frequency
Route
Reason/Purpose for Medication
Known Allergies
Consent
I hereby give permission for the above-named individual to receive the listed over-the-counter medication as directed.
Parent/Guardian Signature
Date