Sms Medication Administration Permission printable pdf download

Sms Medication Administration Permission

2014-2015 SMS Medication Administration Permission and Record Sheet

(one form per child per medication)

Student’s Name____________________________Age/Grade_______Today’s Date___________

Starting Date_____________________________Stopping Date___________________________

Name of Medication______________________________________________________________

Reason for Administration__________________________________________________________

Is this Medication: (circle one)

Over the Counter

Prescription

**prescription medicine needs to be in the original bottle dispensed by the pharmacy with the instructions for

administration on the bottle.

**over the counter medicines must be in the original containers & dose appropriate.

Dosage_____________________________Time Medication to be Given________________

Route: Oral_____________Nasal___left, right,both __________ Eye Drops____left, right, both

Topical___________location to be applied______________Inhaled_________________

Injection_________location to be administered_________________________________

Should Medication be Taken with Food: (circle one)

Yes

Other Specific

Instructions________________________________________________________

Any Previously Known side-Effects___________________________________________________

As the parent/guardian of this child I give my permission for the school staff of St. Monica School to administer the

above medication per the above instructions. I also acknowledge that I have provided the school with the above

medications in accordance with the Archdiocese policy. This can be updated every year via parent initials.

Parent/Guardian Signature________________________________________________2014-2015

2015-2016____________2016-2017___________

Sms Medication Administration Permission