Leave of Absence | Apothecare Inc.

Name*
First Last
Email*
- Date of Departure*
- Date of Return*
- Destination*
Traveling alone? (If no, specify with whom)*
Medications: For each medication and strength specify exactly as on prescription label*
Name Strength Dosage Frequency Route # of Pills Provided
Name Strength Dosage Frequency Route # of Pills Provided
Name Strength Dosage Frequency Route # of Pills Provided
Name Strength Dosage Frequency Route # of Pills Provided
Name Strength Dosage Frequency Route # of Pills Provided
Name Strength Dosage Frequency Route # of Pills Provided
Name Strength Dosage Frequency Route # of Pills Provided
Name Strength Dosage Frequency Route # of Pills Provided
Name Strength Dosage Frequency Route # of Pills Provided
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*
  I 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.

Name	Strength	Dosage	Frequency	Route	# of Pills Provided