Medication Request Form For School
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1__________________________________
School Name
MEDICATION REQUEST FORM
THE SCHOOL ASSUMES NO RESPONSIBILITY FOR NON-MEDICALLY PRESCRIBED
MEDICATION OR MEDICATION ADMINISTERED BY THE PUPIL HIMSELF
No medication will be administered unless:
1. There is a Medication Request Form signed by a Physician/Nurse Practitioner yearly or when there is a
medication change.
2. This form is signed by the parent and principal / designee of the school.
3. The medication is presented by the parent/guardian to the school nurse, principal or designee.
4. The medication is in the original container.
STATEMENT OF PHYSICIAN/NURSE PRACTITIONER
TO BE COMPLETED BY Physician/Nurse Practitioner
Name of Student: ________________________________Date of Birth: ___________ Grade: ________________
Address: ____________________________________________________________________________________
School: _____________________________________________________________________________________
Diagnosis: ___________________________________________________________________________________
Medication/Treatment Required: _________________________________________________________________
Dosage: _________________ Route: ______________ Time/Schedule : __________________________________
Side effects, precautions, special instructions or comments:____________________________________________
____________________________________________________________________________________________
I have examined the above child and determine that the above medication is medically necessary during school
hours.
Physician/NursePractitioner Name
_____________________________________________________
(PleasePrint):
Address:_____________________________________________________________________________________
Telephone: (
) _________________________
Fax: (
) ______________________________
Physician/Nurse Practitioner Signature: ____________________________________________________________
STATEMENT OF PARENT/GUARDIAN
TO BE COMPLETED BY Parent/Guardian
I am unable to persona lly administer the above medication to my child and no member of my family or relative is
able to do so. I request, and hereby authorize, the school to administer the above medication as prescribed. I
consent to the exchange of information between the physician/nurse practitioner with the school nurse regarding the
medication and treatment.
_______________________________
________________________
Signature of Parent/Guardian
Date
______________________________
_______________________
___________________
Home Telephone #
Work Telephone #
Cell phone #
______________________________
________________________
Principal/Designee Signature
Date
MEDIRQST FM6 – REVISED 6/03
RESET
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