School Medication Authorization Form

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School Medication Authorization Form
To be completed by the child’s parent(s)/guardian(s). A new form must be
completed every school year. Keep in the school nurse’s office or, in the absence
of a school nurse, the building’s main office.
Student’s Name:__________________________________Birth Date:____________________
Address:_____________________________________________________________________
Home Phone:_________________________Emergency Phone:_________________________
School:_____________________________Grade:_________Teacher:___________________
To be completed by the student’s physician, physician assistant, or advanced practice RN:
Physician’s printed name:________________________________________________________
Office Address:________________________________________________________________
Office Phone:_________________________Emergency phone:_________________________
Medication Name:______________________________________________________________
Purpose:_____________________________________________________________________
Dosage:_____________________________ Frequency:_______________________________
Time medication is to be administered or under what circumstances:
____________________________________________________________________________
Prescription Date:___________Order date:____________Discontinuation Date:_____________
Diagnosis requiring medication:___________________________________________________
Is it necessary for this medication to be administered during the school day?
Yes
No
Expected side effects, if any:_____________________________________________________
Time interval for re-evaluation:____________________________________________________
Other medications student is receiving:_____________________________________________
_____________________________________________
Physician’s signature
Date
7:270-E
(Parents must complete back of form
)

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