Prescription Medication Form printable pdf download

Prescription Medication Form

5425 Scio Church Rd.

Ann Arbor, MI 48103

734.665.5662

Fax: 734.665.8126

Prescription Medication Form

AUTHORIZATION FOR ADMINISTRATION OF

MEDICATION DURING SCHOOL HOURS

Student’s name: _______________________________

Birth date (mm/dd/yy): ________________

Diagnosis: __________________________________________________________________________________

Name of medication: ________________________________________________________________________

Direction for administration of medication:

____________________________________________________________________________________________

Additional comments:

____________________________________________________________________________________________

Duration of treatment (limited to present school year):

____________________________________________________________________________________________

________________________________________

Physician Name

Physician Signature

___________________________

Physician Registration No.

In the absence of a physician’s signature on this form, please attach a physician’s note.

________________________________________

_______________________

Date

Parent/guardian signature

(mm/dd/yy)

Prescription Medication Form