Administrator: Date:

........Resident: Date:

Per licensing guidelines, the following approval is required for the following medications are to be crushed to enhance taste or facilitate swallowing. Please list ALL medications to be crushed, including Over-The-Counter (OTC). (See PRN Letter of Authorization)

( Check here if OK to Crush & Mix ALL MEDICATIONS with food i.e. apple sauce)

Medication Name
01. ( check here if OK to mix with food i.e. apple sauce )
02. ( check here if OK to mix with food i.e. apple sauce )
03. ( check here if OK to mix with food i.e. apple sauce )
04. ( check here if OK to mix with food i.e. apple sauce )
05. ( check here if OK to mix with food i.e. apple sauce )
06. ( check here if OK to mix with food i.e. apple sauce )
07. ( check here if OK to mix with food i.e. apple sauce )
08. ( check here if OK to mix with food i.e. apple sauce )
09. ( check here if OK to mix with food i.e. apple sauce )
10. ( check here if OK to mix with food i.e. apple sauce )

I give my consent for the medications shown above to be crushed to enhance taste or facilitate swallowing.

Resident/Authorized representative Signature: Date

..........Physician Signature and/or Pharmacist: Date