Student Name:________________________________ Birthdate:__________ Teacher:________________       Grade: __________ School Year:______
To be completed by physician/licensed prescriber only:
    Medication Name Dose Time to be given Form/Route* Side Effects Adverse Reactions
1              
               
               
2              
               
               
*Routes~oral (pill/capsule/chewable, liquid)~inhaled (inhaler, nebulizer)~topical skin application~topical (eye drop, ointment)~topical ear drop~injection~other (list)
List Minimal frequency between doses (especially if p.r.n.):        
If p.r.n., list symptoms/conditions under which medication is to be given:
Reason for medication (optional): Medication #1     Medication #2    
Special Instructions:
Start date if not beginning of the school year: _____________________________________ Stop date if not the end of the school year:___________________________________________
       
Physician's Signature                        Date Physician's Printed Name
Plysicians's Phone #:   Fax:                   Address:    
To be completed by parent/guardian:
Text Box: I request and give permission for (name of child) ________________________________________________to receive the above medication(s) at school according to standard school district policy and for the physician('s)/staff and school district staff to share information needed to assist my child with medication needs. (Schools require parent/guardian to bring medication in its original container).
             
Parent/guardian signature Date