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Frost Valley YMCA Wellness Center2000 Frost Valley Road, Claryville, NY 12725Ph: (845)985-2291 Fax: (845)985-0059 FrostValley.org
Written Doctor and Parent Permission Form
please note: All medications, vitamins, supplements, or topical treatment require
written permission from a physician and parent
Camper Last Name_____________________________________________First Name______________________________________
D.O.B ___________________________________ Weight______________Allergies________________________________________
Physician’s name: ______________________________________________Phone #________________________________________
The following over the counter medications are available in the health center. It is not necessary to send these medications with the
students. These medications can be administered by a Registered Nurse per label instructions by age and weight only if Parent and
Physician signature is documented below. Note: All medications must be sent in original packaging.
Schedule and Indications
To be adminis-
tered if needed
Q 4h as needed for pain or fever>___-F
Q 6h as needed for pain or fever>___-F
(chewable tabs, elixir, suspension or tabs)
Q 4h nasal congestion *not more than 4 doses in 24
Q 6 h as needed for allergic reaction, hives, insect
30 minutes prior to sun exposure as needed for out-
Please document below the patient’s current medication regime for both scheduled and “as needed” medications routinely received by the above noted minor.
Schedule *Be Specific*
Self-carry medication release for Sun block, Rescue inhalers, epi–pens and insulin pumps
We request that the above named camper/student be permitted to carry one or all of the following:
(Please check all that apply and indicate MD order above
The above noted ‘self-carry” items/medications are permitted for the indicated minor at all times. He/She has been instructed by the physician and
parents and acknowledges the proper understanding of the purpose, frequency and appropriate method of use of these items.
As I consider him/ her responsible, I will not hold Frost Valley YMCA personnel responsible for any errors which may arise in my child’s self
administration of these items/medications.
MUst HaVe tHe FolloWInG sIGnatURes oR no oVeR tHe CoUnteR, pResCRIptIon oR selF-CaRRY MeDICatIons Can Be aDMInIsteReD at CaMp
Physician /Health Care providers Signature:
Phone #_______________________________Address: _____________________________________________________________________
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Slutrapport Revision av dokumentation, klassificering och registrering av vårdkontakter inom öppenvård vid Nacka Närsjukhus Proxima AB 25 maj 2011 Staffan Bryngelsson Emendor Consulting AB Innehållsförteckning: Två besök samma datum 2009 och 2010 . 4 6.3 DRG 970O Sjuksköterskebesök 2010 . 10 6.4 Revisorernas sammanfattade kommentarer . 11 7.