Leave of Absence

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