Student Medication Administration Form printable pdf download

Student Medication Administration Form

SCHOOL HEALTH PROGRAM

MEDICATION ADMINISTRATION FORM

I request that the enclosed medication in the original container be administered to my child as

prescribed, and shall release school personnel from all liability. This includes ALL over the

counter medication e.g.Tylenol, Ibuprophen, Benadryl, cough syrup etc.

NAME OF CHILD

GRADE______________________

NAME OF MEDICATION________________________________________________________

DOSAGE______________________________________________________________________

PURPOSE_____________________________________________________________________

_____________________________________________________________________________

)

(parent/guardian signature

(date)

******************************************************************************************************

TO BE FILLED IN BY SCHOOL NURSE

Prescription #

Date_____________________________

Pharmacy

Phone #

Name of Medication_________________

Name of Physician

Phone #___________________________

# Of Tablets Received_____________

******************************************************************************

PHYSICIAN'S ORDERS

Name of Patient________________________________________________________________

Name of Medication_____________________________________________________________

Date of Prescription_____________________________________________________________

Dosage_______________________________________________________________________

Purpose_______________________________________________________________________

COMMENTS__________________________________________________________________

_____________________________________________________________________________

Doctor's Name (please print)

Doctor's Signature

Date

meds form

Student Medication Administration Form