Health Care Provider Authorization And Parent/guardian Consent Form


Hilliard City Schools
Diabetes Management at School
Health Care Provider Authorization and Parent/Guardian Consent
The purpose of this form is to aid the school nurse in gathering the information necessary to develop the student’s
Individualized Health Plan (IHP) and Emergency Care Plan. It must be completed by the student’s health care
provider and reviewed by the parent/guardian. Both parties’ signatures are required on page 3.
Student’s Name: ______________________________________ Date of Birth: _________________________
Grade: ____________________ Known Allergies: _______________________________________________
________ Type 1 Diabetes ________ Type 2 Diabetes
Date of Diagnosis: ______________
Blood Glucose Monitoring
Target Range for glucose level is _________mg/dl to __________mg/dl
Should not exercise if glucose is <_______mg/dl or >__________mg/dl or if ketones are present
Time(s) for routine glucose check: ______________________________________________
Additional tests needed if/when: ________________________________________________
Can student perform his/her own glucose checks? Yes or No (To be verified with parent and nurse)
Exceptions: __________________________________________
Glucose checks are routinely performed in the school clinic unless the health care provider deems an alternative site
necessary. Specialized health care services may be designated to unlicensed school personnel under the training and
supervision of the school nurse.
Medication Authorization for Insulin
By law, the following are required before the nurse or designee may dispense medication to a student.
Medication order, completed and signed by the licensed prescriber
Parent/guardian authorization with signature
Medication in the original container with pharmacy label to match the prescriber’s order
Type and dose of insulin to be taken at school: _______________________ Route: ________ Time: ___________
Type and dose of insulin to be taken at school: _______________________ Route: ________ Time: ___________
If glucose is running high, I authorize an increase in the prescribed dosage by adding ___________units for every
_________ mg/dl over ___________mg/dl
Possible Adverse Reactions: _____________________________________
Special/Storage Instructions: _____________________________________
Can student give his/her own injections? Yes or No
Can student determine correct dose of insulin? Yes or No
Can student draw correct dose of insulin? Yes or No
eginning Date: _________________
Ending Date: ____________________


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