Leave of Absence Form

First Name

Last Name

Date / Time

Destination

Traveling alone? (If no, specify with whom)

Name

Strength

Dosage

Frequency

Route

# of Pills Provided

Special Medication Instructions/Comments or Allergies

Staff who Prepared Medication

Staff who Double-Checked Medication

To Whom are the Medications Entrusted

understand the above information regarding medication and its administration. My questions have been answered. I understand I may call the staff if any further questions arise.