Verbal Medical Order printable pdf download

Verbal Medical Order

SCHOOL NAME

ADDRESS

TELEPHONE

FAX

VERBAL MEDICAL ORDER

– only for School Nurse/Associate School Nurse use

TO: ___________________________________

Student Name/DOB

___________________________________

__________________________

___________________________________

__________________________

Faxed orders with licensed provider electronic signature and initialed by sending RN is/ is not

acceptable (please circle your choice)

New MEDICATION, SERVICE And/or TREATMENT ORDERED

For meds specify details, including end date:

Start

End

MEDICATION CHANGES

Strength of

Dose

Route

Time

Date

Medication Name

med.

Page ____ of ______

SCHOOL NURSE: ___________________________________________________

SIGNATURE/TITLE OF SCHOOL NURSE ACCEPTING ORDERS:

________________________________________________________________ DATE: _______________

PRINTED NAME OF Licensed Provider:

________________________________________________________________DATE: _______________

SIGNATURE OF Licensed Provider:

________________________________________________________________

This order is valid for one dose only until signed and dated by licensed prescribing provider

Verbal Medical Order