This form provides your written consent for us to administer the listed medications. You must also submit a medication administration authorization form signed by a licensed health care provider.
In the side effects field list any possible side effects.
If the medication is to be administered only on an as needed basis then:
(1) in the Time/frequency field write PRN and the frequency of administration when symptoms occur,
(2) in the PRN symptoms field describe the symptoms that require administration of this medication