Administration Of Medication Consent Form

ADVERTISEMENT

SAGINAW TOWNSHIP COMMUNITY SCHOOLS
ADMINISTRATION OF MEDICATION CONSENT FORM
Student’s Name______________________________________________________
Birthdate___________________Grade____________Today’s Date_____________
Medication Information
(To be completed by Health Care Provider)
Name of Medication________________________________________
ddddddd
Purpose of Medication______________________________________
Dosage____________________Route & Frequency______________
Expiration Date_________Time to Administer Medication_________
Directions for Administration_________________________________
Length of Time Medication will be prescribed____________________
Side Effect of Medication/Comments___________________________
Restrictions
Yes
If yes, what and how long?_____________________
No
For Inhaled/Injected Medication- Asthma Management Plan/Allergy Action Plan Completed
I have instructed student in the proper way to use his/her inhaler/Epi Pen. It is my
professional opinion that he/she be allowed to carry and use the inhaler/Epi Pen by
him/herself.
It is my professional opinion that the student should not carry or administer inhaler/Epi Pen
by him/herself.
Attending Physician_____________________________________Date____________
Signature
Printed Name & Address of Physician_________________________________________
I hereby request that my child be administered the prescribed medication at school by designated school personnel. I
understand that the medication will be administered as per the directions of the above named physician. I will notify the
school of changes or discontinuance of this medication(s) immediately
.
Parent/Guardian________________________________________Date____________
signature
Address_______________________________________________Phone___________
M.C.L.A. S 380.1178 states the following “ a school administrator, teacher or other school employee designed by the
school administrator, who in good faith administers medication to a pupil in the presence of another adult pursuant to
written permission of the pupil’s parent or guardian and in compliance with the instructions of the physician is not
liable in criminal action or for civil damage as a result of administration except for an act or omission amounting to
gross negligence or willful and wanton misconduct.” File in CA60

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go