Formulaire d’autorisation à administrer un médicament et fiche de traitement Nom du milieu de garde / logo
Nom de l’enfant : ______________________________________________________________________________ Date :___________________________________________
I : À faire remplir par un parent ou un tuteur de l’enfant
Je, _____________________________________________ [nom du parent ou du tuteur], autorise le personnel du milieu de garde à administrer le médicament suivant à ______________________________ [nom de l’enfant], conformément aux directives précisées ci-dessous. Signature du parent ou du tuteur : ________________________________________________________________ Nom du médicament : __________________________________________________________________________ ____________________________________________________________________________________________ Quantité à administrer : ________________________________________________________________________ ____________________________________________________________________________________________ Date(s) d’administration [au milieu de garde] : ______________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Heure(s) d’administration : ______________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Nom, adresse et numéro de téléphone du milieu de garde
Directives spéciales : __________________________________________________________________________ ____________________________________________________________________________________________ Entreposage : ________________________________________________________________________________ ____________________________________________________________________________________________ Date de début : ___________________________________ Date de fin : ________________________________ Mon enfant a reçu ______ [nombre] doses à la maison. Le médicament peut-il provoquer des effets secondaires? Précisez : ______________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Interrompez l’administration en présence des réactions suivantes : ______________________________________ ____________________________________________________________________________________________
II: À faire remplir par l’éducatrice lors de l’administration du médicament
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