Please provide the following information in the form:

Release of Medication Form

* = Required Information

Client *

Date Medication(s) Left the Facility *

Expected Return Date *

Medications Sent Home

Medication

Use

Amount Prepared

Amount Returned

Add Another Medication

Medication Schedule

Time

Medication/Dose

Directions

Add Another Medication

The above medications were released to *

I, , accept full responsibility for seeing that the above medications are given as directed to .

Signature *

Date *

Signature *

Date *

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