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*
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*

Clear
Date*

MonthDayYear
Date
Home Phone Number - Parent/Legal Guardian*
Work Phone Number - Parent/Legal Guardian*
Should be Empty: