Written order from an authorized prescriber/parent’s permission

Phyllis Bodel Childcare Center at Yale School of Medicine, Inc. Written Order from an Authorized Prescriber/Parent’s Permission

If a Child Day Care Center, A Group Day Care Home or a Family Day Care Home chooses to administer medications, the
Connecticut State Law and Regulations require a physician's, dentist's or advanced practice registered nurses' written order
and parent or guardian's authorizations for a nurse, the director, teacher or day care provider to administer medications.
Medications must be in the original pharmacy prepared containers and labeled with the name of child, name of drug, strength,
dosage, frequency, name of prescriber, and date of original prescription. Over the counter medication must be in the original
container and labeled with the child's name.

Physician, Dentist, Advanced Practice Registered Nurse or Physician Assistant
1. Name of Child ____________________________________________________ Date of Birth _________
Address _________________________________________________________
Condition for which medication is being administered during day care hours: ______________________________
2. Medication:_
_Benadryl (Diphenhydramine) 12.5 mg/ 5cc___________ Date of Order: ______________________
3. Dose ____________ 4. Route: __________
5. Time:
according to emergency health care plan for severe allergy Medication shall be administered from ________________________ to ___________________________________ Side effects to be observed, if any: ___________________________________________
Is this a controlled medication? __________ Allergies to food or medications? If yes, list _____________________
Interaction of medication with food: _______________________
Name of Licensed Prescriber ______________________________________ Telephone ____________________
Address ____________________________________ Licensed Prescriber signature ________________________

Authorization by Parent/Guardian for the administration of the above medication: Date: _______________
I hereby request that the above medication, ordered by the physician/dentist/advanced practice registered nurse for my child
_________________________, be administered by the nurse, director, or teacher. I confirm that I have given at least one
dose of the medication without any evidence of side effects or adverse reactions. I understand that I must supply the Child
Day Care Center, Group Day Care Home or Family Day Care Home with the prescribed medication on the original container
dispensed and properly labeled by a physician or pharmacist. Over the counter medication shall be in the original container
labeled by the parent with the child's name. I understand that this medication will be destroyed if it is not picked up within one
week following termination of the order.
I authorize my child care provider/program to contact the pharmacist or prescriber for more information, if necessary, about
this drug and side effects:

Name Parent/ Guardian_____________________________________ Signature _____________________________
Address: ____________________________________________________________________________ Relationship to Child ______________________________ Telephone __________________________
Signature of Certified Child Care Provider receiving and reviewing this form:

Source: http://bodelchildcare.org/links/benadrylauth.pdf