AUTHORIZATION FOR ADMINISTRATION OF ORAL MEDICATION AT SCHOOL
Student Name: _____________________________ Birth Date: ________________
School: ___________________________________ Grade: ___________________
THIS PORTION TO BE COMPLETED BY THE PHYSICIAN/DENTIST
| Name of Medication | Dosage | Methods of Administration | Time of Day to Be Taken |
| ________________ | ________ | _____________________ | ____________________ |
If given prn specify the length of time between doses ________________________
Inhalers: ________________________________________________________
Indicate if student must carry on his/her person ____________
Possible side effects of medication _____________________________________
Emergency procedure in case of serious side effects ________________________
I request and authorize that the above-named student be administered the above identified oral medication in accordance with the instructions indicated above from __________ to_____________ (not to exceed current school year) as there exists a valid health reason, which makes administration of the medication advisable during school hours.
_______________________________ __________________________________
Date of Signature Physician/Dentist Signature
Telephone Number: ________________ Name: ____________________________
Please Note: If samples of medication are to be given, they must be labeled with the name of the student, dosage, and time to be given.
I request/authorize the school to administer medication to the above identified student in accordance with the doctor's instructions for the period from ______ to _______ (not to exceed current school year). I understand that every effort will be made by school staff to administer the medication in a timely manner.
□ Permission to carry inhaler
_______________________________ __________________________________
Date of Signature Parent/Guardian Signature
Telephone Number: ________________(home) ________________________ (work)