Fillable Medreleaseform Medication Release Form (North Carolina)

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Medreleaseform Medication Release Form (North Carolina)

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DHSR/AC 4693 NCDHHS Rev.03/2015
MEDICATION RELEASE FORM
FOR RESIDENT LEAVE OF ABSENCE
Facility Name:
Resident:
Room #:
Date of Departure:
Date of Return:
Day(s) Supply of the Following Medication(s) Provided:
Medication
Strength
Directions & Cautionary Information*
*provide Cautionary Info if not on label
Quantity
upon leaving
Quantity
upon return
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Verbal instructions from staff to resident or person accompanying resident to include the following:
1. Review above information for each
medication.
5. Staff/Resident/Person accompanying resident check to ensure
sufficient
amount of medication has been released until expected return.
2. Read all directions carefully.
6. Discuss facility policy and procedure for return of unused
medications.
3. Give each dose exactly as ordered by
physician.
7. Other -
4. Store all medications away from children.
****************************************************************************************
***
Staff Signature*:
Date:
Staff Printed Name:
*Signature of staff person who released medications and provided verbal instructions above.
DHSR/AC 4693 NCDHHS Rev.03/2015
Receipt Acknowledgement:
I have been instructed in the proper usage, dosage, frequency and reason for each medication provided. I accept
responsibility for the medication and will assure that it is properly stored and that it is properly administered. I
understand that in the event that the drugs are accepted in non-child proof containers, I hereby release the facility named
above and the pharmacy from responsibility.
Signature of Resident or Person
Accompanying Resident:
Date:
(Relationship)
****************************************************************************************
***
Medications Returned (Quantity returned documented above.)
Date and Time:
Staff Signature:
Signature of Resident or Person
Accompanying Resident:
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Medreleaseform Medication Release Form (North Carolina)

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Completed 19 January 2022

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