HILLSBOROUGH TOWNSHIP SCHOOL SYSTEM
HEALTH DEPARTMENT
PHOTO
MEDICATION FORM FOR LIFE THREATENING ALLERGIC REACTION
HERE
TO BE COMPLETED BY HEALTHCARE PROVIDER
Student Name___________________________ D.O.B.________ Gr.___
Allergen(s)_____________________________________________________
Symptoms in past_______________________________________
Epinephrine required in past? _______Yes
or
______No
History of Asthma
_______Yes
or
______No
Epinephrine: inject intramuscularly (circle one)
0.3 mg
or
0.15 mg
Epinephrine may be repeated, if necessary, in _________ minutes.
Antihistamine: Name _____________________Dose ____________________ Route _________
May student self-administer the medication prescribed (epinephrine and antihistamine)? ___Yes
___No
If yes, please complete next two questions:
___Yes ___No Student understands the purpose, proper technique of administration and frequency of use of
the medication prescribed above and is capable of self-administration of the medication.
___Yes ___No Student is aware that he/she must immediately report to the school nurse or teacher if he/she
has a suspected exposure to allergen, any signs of allergic reaction, or has used medication.
Physician/Healthcare Provider’s Signature__________________________________ Date__________
OFFICE STAMP
These orders are valid from September 1, _________ through August 31, __________
*****ALL MEDICATION ORDERS MUST BE RENEWED ANNUALLY*****
**PARENT/GUARDIAN MEDICATION REQUEST SECTION-To be completed by the Parent/Guardian**
I hereby give permission for my child to receive medication at school as prescribed above by my child’s physician. I also give permission
for the release and exchange of information between the school nurse and my child’s physician concerning my child’s health and
treatment.
Date: __________________
Parent/Guardian Signature: ______________________________________
SIDE 2 TO BE COMPLETED BY PARENT
Revised 8/14