Request to Administer Medication

Request to Administer Medication
NOTICE TO PARENTS: The parent/legal guardian must bring medication to school in original container that is appropriately labeled by the pharmacy or physician.
Name of Student (Last, First, MI)
Student’s Date of Birth

MonthDayYear
Date
Student’s Diagnosis
Medication
Dosage - must match medication label
Time of Administration - be specific, "as needed" is not clear, list symptoms to watch for and/or how often to administer - must match medication label
Method of Administration and Instructions
Start Date

MonthDayYear
Date
End Date (must match medication label)

MonthDayYear
Date
Physician/Nurse Practitioner/Physician’s Assistant/Dentist’s Name
Physician/Nurse Practitioner/Physician’s Assistant/Dentist’s Phone Number
Format: (000) 000-0000.
PARENT/LEGAL GUARDIAN: I hereby give permission for the school to administer the medication as prescribed above. I also give permission for the school to contact the above health care provider regarding the administration of this medication.
Signature – Parent/Legal Guardian
Date

MonthDayYear
Date
Home Phone Number - Parent/Legal Guardian
Format: (000) 000-0000.
Work Phone Number - Parent/Legal Guardian
Format: (000) 000-0000.
Should be Empty: