ASSISTED LIVING

MEDICATION ADMINISTRATION RELEASE

Resident’s Name: ____________________________________________ Suite #: _________

RE: Medication Administration

I understand that I have directed my medications. However, I choose to take my medication on

my own, at a time of my choosing, and to have it left for me in my suite.

I hereby release The Weinberg Residence and all others related to my care, of any liability or
responsibility in regard to the action described above.

________________________________________ ___________________
Signature of Resident Date

________________________________________ ___________________
Signature and Relationship of Responsible Other Date

________________________________________ ___________________
Signature and Position Title of Witness Date

Physician aware Y □ N □

Note: _________________________________________________________________

October 4, 2018