Lotion or Lip Balm Over the Counter

This form is valid for no longer than twelve (12) months. One form must be used for each medication.

Check all that apply:

Topical Product or lotion Lip Balm

Name of child:

Date of birth:

Weight

Name of Topical product:

Exact Dosage:

To be administered at the following times:

For the following period of time:

*Topical product must be applied at least once at home to avoid any unexpected reactions.

Parent / Guardian signature:

Date

This form must be used by child care centers to meet the requirement of OAC Rule 5180: 2-12-25

(Rev. 1/2/25)