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Leave of Absence Form
Name
*
First
Last
Email
*
Date of Departure
*
MM slash DD slash YYYY
Date of Return
*
MM slash DD slash YYYY
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.
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