Medication Order Form - Louisiana
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1STATE OF LOUISIANA
MEDICATION ORDER
TO BE COMPLETED BY LA, TX, AR, OR MS LICENSED PRESCRIBER
(In most instances, medications will be administered by unlicensed personnel.)
PART 1: PARENT OR LEGAL GUARDIAN TO COMPLETE.
Student’s Name ______________________________________________ Birthdate _______________
School _____________________________________________________ Grade _________________
Parent or Legal Guardian Name (print): ________________________________________________
Parent or Legal Guardian Signature:______________________________________________
Date:__________
(Please note: A parental/legal guardian consent form must also be filled out. Obtain from the school nurse.)
PART 2: LICENSED PRESCRIBER TO COMPLETE.
1.
Relevant Diagnosis(es): ______________________________________________________________
2.
Student’s General Health Status: _______________________________________________________
3.
Medication: ________________________________________________________________________
4.
Strength of medication: ___________________ Dosage (amount to be given): ___________________
Check Route: ❑ By mouth
❑ By inhalation
❑ Other __________________________
Frequency ____________________________ Time of each dose _____________________
___________________________________________________________________________
School medication orders shall be limited to medication that cannot be administered before or after
school hours. Special circumstances must be approved by school nurse.
Duration of medication order: ❑ Until end of school term
❑ Other ____________________
5.
6.
Desired Effect: _____________________________________________________________________
7.
Possible side-effects of medication: ____________________________________________________
8.
Any contraindications for administering medication: ________________________________________
_________________________________________________________________________________
9.
Other medications being taken by student when not at school:
_________________________________________________________________________________
_________________________________________________________________________________
10.
Next visit is: _____________________________________
___________________________________________________________________________________
Prescriber’s Name (Printed)
Address
Phone and Fax Numbers
__________________________________________________________________________________________
Prescriber’s Signature
Credential (i.e., MD, NP, DDS)
Date
Each medication order must be written on a separate order form. Any future changes in directions for medication ordered require new
medications orders. Orders sent by fax are acceptable. Legibility may require mailing original to the school. Orders to discontinue also must be
written.
PART 3: LICENSED PRESCRIBER TO COMPLETE AS APPROPRIATE.
Inhalants / Emergency Drugs
Release Form for Students to be Allowed to Carry Medication on His/Her Person
Use this space only for students who will self-administer medication such as asthma inhaler.
❑ Yes
❑ No
1. Is the student a candidate for self-administration training?
2. Has this student been adequately instructed by you or your staff and demonstrated competence in self-
administration of medication to the degree that he/she may self-administer his/her medication at school,
provided that the school nurse has determined it is safe and appropriate for this student in his/her particular
school setting? ❑ Yes
❑ No
❑Yes
❑ No
3. If training has not occurred, may the school nurse conduct a training program?
_____________________________________________________________________________
Licensed Provider’s Signature
Date
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