Physician Form For Administration Of Medication printable pdf download

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PHYSICIAN FORM FOR ADMINISTRATION OF MEDICATION

AND SELF MEDICATION ADMINISTRATION

THIS FORM IS GOOD FOR UP TO ONE SCHOOL YEAR ONLY.

The following is to be completed by a health care provider (physician/nurse practitioner). No medication of any kind will be given to

your child until this information is completed and returned to the school.

• All medication must be in a pharmacy-labeled container. NOTE: Over the counter medication prescribed by a physician/nurse

practitioner must be brought to school in an unopened original container.

• If any changes in medication occur during the school year, a new form must be completed along with a new pharmacy/physician-

labeled container and returned to the school.

• Only one form for each medication is to be used.

• Medication must be brought to school by a responsible adult. Please do not send medication by children.

• A parent signature is required before a student can be assisted with self medication.

TO BE COMPLETED BY PARENT:

Name of student

Date of Birth

School

Grade

Teacher

I hereby give consent for my child to be assisted in taking the medication described below at school. I also authorize, as needed, the

sharing of information related to my child's health between the school nurse (or designee) and the health care provider listed below.

I will comply with the policy listed on the back of this form related to dispensing medication at school.

Date

Parent / Guardian Signature

Home Phone

Work Phone

Mother's Cell Phone __________________________________

Father's Cell Phone _________________________________

Emergency Contact (Name and Phone)

TO BE COMPLETED BY HEALTH CARE PROVIDER ONLY:

Diagnosis for which medication is given

Name of medication

Dosage

Start Date ________________________________ Stop Date ________________________________

Form _______ Route _______ Special Handling Instructions:

refrigeration

keep out of sunlight

other ________________

If medication is to be be given daily, at what time?

A.M.

P.M.

Dates must be administered at school:

Every day at school

Episodic/Emergency events only

Short term (list dates to be given) _____________________

If medication is to be given “when needed”, describe symptoms student will exhibit.

How soon can it be repeated?

Possible side effects and procedure to follow

Physician's/Nurse Practitioner's Name (Print)

Physician's/Nurse Practioner's Signature

Date

Address

Zip Code

Phone

Fax

(School Staff Only) Completed form received on

Date

Signature

Expiration Date of Medication (if available)

AD–H–326 (5/08)

P.O. Box 2188 • 912 South Gay Street • Knoxville, Tennessee 37901-2188 • Telephone (865) 594-1800

Physician Form For Administration Of Medication

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