Permission for Over-the-Counter Topical Medications and Fluoridated Toothpaste

Child's Name *

First

Last

Permission is given to apply the following (name/type)

Amount/Dosage *

Fluoridated toothpaste should be a rice sized smear for children under 3 and pea sized for children 3 and over.

Expiration date, if applicable

Permission Start Date

Permission may be given for up to 12 months.

Permission End Date

Application area *

If OTHER AREA, please specify

Application needed *

If OTHER NEED, please specify

Application Instructions

Parent/Guardian Approval *

First

Last

I give permission to my child care provider to apply the medication listed above as instructed.

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