DREAMS AND VISION, LLC CONSENT FOR OVER-THE-COUNTER MEDICATION Dreams and Vision LLC, has my permission to administer the following over-the-counter medications to __________________________________________. I understand that these medications will be administered when the symptoms warrant and according to the directions. MEDICATION FOR EXTERNAL TREATMENT Neosporin Minor burns, cuts, and abrasions First Aid Spray Scrapes, cuts, and minor burns Calamine lotion (with or without Phenol) Allergic rashes (poison ivy, oak, etc.) Rubbing alcohol Insect Betadine scrubs, hydrogen peroxide Cleaning area of minor injury Hydrocortisone Cream Rashes, itching, skin irritation MEDICATION FOR INTERNAL TREATMENT Metamucil/Milk of Magnesia Constipation Acetaminophen Headaches or minor pain Pepto-Bismol Upset stomach Robitussin/Dimetapp sneezing, watery eyes, congestion Cepacol or Chloraceptic Sore Throat Benadryl caps Allergic reaction (stings) antihistamine Lpecac syrup Induce vomiting (cleared with physician) Ibuprofen Fever, inflammation, pain __________________________________ ______________________ Signature of legal guardian Date __________________________________ ______________________ Signature of Consulting Psychiatrist Date
DREAMS AND VISION, LLC CONSENT FOR OVER-THE-COUNTER MEDICATION Dreams and Vision LLC, has my permission to administer the following over-the-counter medications to __________________________________________. I understand that these medications will be administered when the symptoms warrant and according to the directions. MEDICATION Neosporin First Aid Spray Calamine lotion (with or without Phenol) Rubbing alcohol Betadine scrubs, hydrogen peroxide Hydrocortisone Cream MEDICATION Metamucil/Milk of Magnesia Acetaminophen Pepto-Bismol Robitussin/Dimetapp Cepacol or Chloraceptic Benadryl caps Lpecac syrup Ibuprofen __________________________________ Signature of legal guardian __________________________________ Signature of Consulting Psychiatrist FOR EXTERNAL TREATMENT Minor burns, cuts, and abrasions Scrapes, cuts, and minor burns Allergic rashes (poison ivy, oak, etc.) Insect Cleaning area of minor injury Rashes, itching, skin irritation FOR INTERNAL TREATMENT Constipation Headaches or minor pain Upset stomach sneezing, watery eyes, congestion Sore Throat Allergic reaction (stings) antihistamine Induce vomiting (cleared with physician) Fever, inflammation, pain ______________________ Date ______________________ Date
intake_applicationpdf.301112942.docx