BedpanCommando
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My company has a form that goes something like this.
Over the Counter (OTC) medication responsibility release...
I acknowledge that by signing this form that:
1. I am solely responsible for the correct usage of this OTC medication. This includes correct dosage, administration and dosing intervals.
2. I have no allergies to this particular OTC medication.
3. I am aware that every medication has the potential to have an adverse reaction and I understand that any adverse reaction is my own responsibility.
4. I agree that (Name of company) and the medical provider assigned to this site have no responsibility for my voluntary use of this OTC medication.
Patient Name (Printed): ___________________________________________
Patient Signature: ___________________________________________
Witness Name (Printed): ___________________________________________
Witness Signature: ____________________________________________
All persons wanting any OTC meds from my stock must read and sign this form before and meds are given out. Simply stating "I'm not responsible" is not enough you must document.
Over the Counter (OTC) medication responsibility release...
I acknowledge that by signing this form that:
1. I am solely responsible for the correct usage of this OTC medication. This includes correct dosage, administration and dosing intervals.
2. I have no allergies to this particular OTC medication.
3. I am aware that every medication has the potential to have an adverse reaction and I understand that any adverse reaction is my own responsibility.
4. I agree that (Name of company) and the medical provider assigned to this site have no responsibility for my voluntary use of this OTC medication.
Patient Name (Printed): ___________________________________________
Patient Signature: ___________________________________________
Witness Name (Printed): ___________________________________________
Witness Signature: ____________________________________________
All persons wanting any OTC meds from my stock must read and sign this form before and meds are given out. Simply stating "I'm not responsible" is not enough you must document.
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