Medication Dispensing Form Pennsylvania (Page 2 of 2) in pdf

CENTRAL BUCK SCHOOL DISTRICT

20 WELDEN DRIVE, DOYLESTOWN, Pennsylvania - 267-893-2000

MEDICATION DISPENSING FORM

 All medication, whether prescription or over-the-counter, must be kept in the school health room and

be accompanied by a healthcare provider’s order. The protocol for students requiring medication in

school is as follows:

o The health care provider must complete the top part of the form; parents/guardians must sign

the bottom section, giving your permission to administer the medication in school.

o We will accept an order on a private prescription form attached to this page with

parent/guardian signature in place.

Medication will not be administered to any student in school without completed orders in

place. Failure to provide documentation will require the parent/guardian to be present in

school to administer the medicine personally.

o Medications must be brought to school in the original labeled container and given to the

school/staff nurse. All controlled medications i.e. Ritalin, Concerta, Adderall must be

delivered to the school nurse by an adult, counted and recorded on the student’s medication

log.

TO BE COMPLETED BY PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN’S ASSISTANT/DENTIST

STUDENT’S NAME: _________________________________AGE:_______GRADE:_________SCHOOL:_______________

NAME OF MEDICATION: ________________________________DOSAGE:_________________FREQUENCY:___________

SPECIAL CONSIDERATIONS: ___________________________________________________________________________

REASON FOR MEDICATION: ___________________________________________________________________________

EFFECTIVE DATES:

FROM: ______________________ TO: ________________________

is my understanding that the employees of the Central Bucks School District charged with the administration of this

treatment/procedure during school hours rely on directions contained in this document. I further certify that I am the health care

provider who prescribed the treatment and that the student named above is under my supervision as a patient.

SIGNATURE OF HEALTH CARE PROVIDER: ____________________________________________________________________

PRINTED NAME OF HEALTH CARE PROVIDER: _________________________________________________________________

ADDRESS: ______________________________________________________________________________________________

TELEPHONE: _______________________________FAX: _____________________________DATE: _______________________

TO BE COMPLETED BY PARENT/GUARDIAN

As the parent/guardian of the above named student, I hereby request that the treatment described above be administered to my child and

release the Central Bucks School District and its employees from liability for any damages my child may suffer as a result of this request.

Signature of Parent/Guardian: __________________________________________________________________________________________

Home Phone: _____________________________ Cell Phone: _______________________________ Work Phone: ______________________

CB 418 (rev 09.2013)

Medication Dispensing Form Pennsylvania Page 2