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Get AZ DHS CCL Form 302 2011-2024

Ription #: Dosage: Start date: End Date: Times & frequency: Route (method)*: REASON: I give permission for the administration of the medication, according to the instructions listed, to the child listed above. Date of authorization: Signature (parent/guardian): POSSIBLE SIDE EFFECTS TO WATCH FOR WITH THIS MEDICATION: * Injections: Attach health care provider’s written authorization. ****************************************** FOR STAFF REVIEW PRIOR TO ADMINISTERING MEDICATION: YES .

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