Medication Authorization Form – West Side Helping Hand

Authorization For Dispensing Medication Form

If your child requires medication please fill out the following form. If your child does NOT require medication you can now close this window.

Texas Dept of Family and Protective Services - Form 7238

Name of Child to Receive Medicine

Name of Medication

Prescribing Physician

Prescription No.

Expiration Date

Dosage

When to Give?

Continue Medication Until (Date)

NOTE: Medication must be in its original container and labeled with your child’s name and the date medication is left at the facility. Medication can only be administered in amounts according to the label directions.

Parent/Guardian Signature

Date