Medication and Topical-Care Authorization

Version 2026.1 · Effective August 23, 2026

Child and parent

• Child’s full name: ______________________________________________
• Date of birth: ____________________
• Parent/guardian: _______________________________________________

Product or medication

• Name: _________________________________________________________
• Purpose: ______________________________________________________
• Type: ☐ Prescription ☐ Over-the-counter ☐ Sunscreen ☐ Lotion/cream/balm ☐ Diaper ointment ☐ Other: __________
• Amount/dose: __________________________________________________
• Frequency/timing: ______________________________________________
• Start date: ____________________ End date: ____________________

Instructions and health-provider information

Instructions: ___________________________________________________

__________________________________________________________________

• Healthcare provider: ___________________________________________
• Provider phone: _______________________________________________

☐ Healthcare-provider order or instructions attached, when required.

Parent authorization

I authorize Teida’s Tots to administer or apply the product identified above according to the written instructions and applicable procedures. I have disclosed known allergies, reactions, and relevant health information.

☐ My child may use only the product supplied by me.

☐ The product may be supplied by Teida’s Tots, if separately approved and identified here: __________________________________________________________

Product handling

The parent must provide the product in its original container, labeled with the child’s name, and within its expiration date. Teida’s Tots will follow applicable storage, administration, documentation, and parent-notification procedures. Any observed reaction will be reported promptly and handled according to the emergency and health procedures.

Signatures

• Parent/guardian signature: ______________________________________
• Printed name: _________________________________________________
• Date: ____________________

• Provider signature: ____________________________________________
• Date: ____________________

Provider administration record