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MM slash DD slash YYYY
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MM slash DD slash YYYY
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List medication name, Dr. who prescribed it, reason needed and how long the child has been taking the prescription.
List then explain
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Click on all applicable. Hold down Command key to choose more than one.
Check each box that applies.
MM slash DD slash YYYY
Check most appropriate option.
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Check most appropriate option.
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Check most appropriate option.
Check most appropriate option.
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Signature of Guardian
Signature of Child