* = Required Information
Client
*
Date Medication(s) Left the Facility
*
Expected Return Date
*
Medications Sent Home
Medication
Use
Amount Prepared
Amount Returned
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Medication Schedule
Time
Medication/Dose
Directions
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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
*
Submit