Sunscreen Authorization Form

Sunscreen Authorization Form

(Program-Provided/Bulk Sunscreen)
  • Name of Sunscreen & SPF: Rocky Mountain Sunscreen SPF 50

    Active Ingredients: Avobenzone—3.0%, Homosalate—15.0%, Octisalate— 5.0%, Octocrylene—10.0%

    Possible Side Effects:

    Other Label Information: Inactive Ingredients: Acrylates/Octylacrylamide Copolymer, Alcohol Denat., Caprylic/Capric Triglyceride, Diethylhexyl Syringylidenemalonate, Glycerin, Stearoxytrimethylsilane, Tocopherol.

    Rocky Mountain Sunscreen lotions and sprays do not include:

    • Oxybenzone
    • Octinoxate
    • Nut oil
    • Gluten
    • Glycol
    • PABA
    • Casein
    • Silicone
    • Retinyl Palmitate

    Reason for medication: Protection from sun

    Amount to be given: Cover exposed areas of skin

    Route: Topical

    Times to be applied: 30 mintues before exposure to the sun, and reapplied every two hours if remaining outdoors.

    Storage: Room temperature