School Medication Authorization Form printable pdf download

School Medication Authorization Form

LAKE PARK HIGH SCHOOL DISTRICT NO. 108

SCHOOL MEDICATION AUTHORIZATION FORM

(Page 2 of 2, Physician’s Order)

(To be completed by a medical professional authorized to prescribe medication, i.e. physician, dentist,

podiatrist, optometrist, physician assistant, or advanced practice registered nurse.)

*Administering medication during school hours or during school-related activities is discouraged

unless it is necessary for the critical health and well-being of the student.

Student Name ___________________

_____________

_ Date

___________

Medication

______ Dosage ______ _____________ ___________

Time Given/Instructions

_______ Route _____________Starting Date ________________

End Date

(form must be renewed each year)

Special circumstances when medication should be given

________________________

Diagnosis requiring medication

________________________

Purpose for medication

________________________

Possible side effects

__________________

Is it necessary for this medication to be administered during the school day? (please check) ( ) Yes

( ) No

May student self-administer asthma or epinephrine medication? (please check) ( ) Yes

( ) No

If yes, I certify that the student has been instructed in the use and self-administration of the

medication. He/she is capable of using this medication independently.

Other medications student is receiving

__________________

___________________________________________________________________________________

Other instructions for school personnel

__________________

___________________________________________________________________________________

Authorized Medical Professional’s Name (Print)

_______________________

Authorized Medical Professional’s Signature:

__________________

Medical Professional’s Address:

_______________________

__________________

___________________________________________________________________________________

Medical Professional’s Telephone Number:

__________________

Emergency Telephone Number:

__________________

School Medication Authorization Form

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