Daily Medication Log

ADVERTISEMENT

M
V
C
S
D
INISINK
ALLEY
ENTRAL
CHOOL
ISTRICT
Office of the School Nurse
PO Box 217, Slate Hill, NY 10973
Daily Medication Log
Authorization for Administration of Medication
TO BE COMPLETED BY PARENT OR GUARDIAN:
I request that my child ______________________________________ grade _______ receive the medication
as prescribed below by our licensed health care prescriber. The medication is to be furnished by me in the
properly labeled original container from the pharmacy. I understand that the school nurse, or other
designated person in the absence of the school nurse, will administer the medication.
Signature Parent/Guardian:
Date:
Address:
Home Phone:
Work Phone:
Cell Number:
TO BE COMPLETED BY THE LICENSED HEALTH CAR PRESCRIBER:
I request that my patient, as listed below receive the following medication:
Name of Student:
Date of Birth:
Diagnosis:
Name of Medication:
Prescribed dosage, frequency and route of administration:
Time to be taken during school hours:
Duration of treatment:
Possible side effects and adverse reactions (if any):
Other recommendations:
Name of licensed prescriber and title (please print):
Prescriber’s Signature:
Date:
Address:
Phone:
Rev. 2004

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go