Parent Guardian And Authorized Health Care Provider Request For Medication Form printable pdf download

IUSD HEALTH SERVICES

PHONE: 949-936-7920

FAX: 949-936-7929

PARENT/GUARDIAN AND AUTHORIZED HEALTH CARE PROVIDER REQUEST FOR MEDICATION

Student Name

Birthdate

School & Year

Grade

Telephone – Home

Telephone - Work

Telephone - Cell

Teacher

PARENT REQUEST FOR THE ADMINISTRATION OF MEDICATION

PRESCRIPTION AND NON-PRESCRIPTION

California Education Code Section 49423 allows the school nurse or other designated non-medical school personnel to

assist students who are required to take medication during the school day. This service is provided to enable the student

to remain in school and to maintain or improve his/her potential for education and learning.

I request that medication be administered to my child in accordance with our authorized health care provider written

instruction. I understand that designated non-medical school personnel may assist in carrying out written orders under

supervision of a qualified school nurse. I will notify the school immediately and submit a new form if there are changes in

medication, dosage, time of administration, and/or the prescribing authorized health care provider. I give permission for

the school nurse to exchange medication-related information with the authorized health care provider. The school nurse

may counsel appropriate school personnel regarding the medication and its possible effects.

Parent/Guardian Signature:

Date:

Emergency medicine such as an EpiPen or inhaler may be carried by the student when recommended by an

authorized health care provider and parent. Back up medication should be kept at school for emergency use.

All medication must be in the student’s original, labeled pharmacy container. The directions for administration on the

school container must be in English. You may request additional containers from your pharmacist, one for school and one

for home, if needed.

AUTHORIZED HEALTH CARE PROVIDER

REQUEST FOR ADMINISTRATION OF MEDICATION

Reason for medication (diagnosis):

Medication:

Dose:

Route:

Time:

If PRN: Amount of time between doses:

Maximum number of doses per school day:

Possible medication reactions:

Instructions for emergency care:

Date of request:

Date to discontinue medication:

The above medication cannot be scheduled for other than during school hours and non-medical school personnel may

assist with the administration under the supervision of a qualified school nurse.

Authorized Health Care Provider Signature

Date

Address

Telephone Number

Fax

Office Stamp

Regarding EpiPens/Inhalers: It is my professional opinion that this student should be permitted to carry/self administer this

emergency EpiPen or inhaler. This student has been instructed in, and demonstrates an understanding of proper usage.

Health Care Provider Initials:

SCHOOL USE ONLY:

Reviewed by:

Date:

THIS REQUEST IS VALID FOR THE CURRENT SCHOOL YEAR

Revised 07-29-09

Parent Guardian And Authorized Health Care Provider Request For Medication Form

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