MEDICATION CONSENT FORM

MEDICATION CONSENT FORM

Please fill out this form completely to the best of your ability. Be sure to bring your child's medication and or epipen to the office on or before their first day of school.
First & Last Name of child*
Type/Name of Medication*
Prescription #*
Dosage*
Route (method)*
Start date

MonthDayYear
Date
End Date

MonthDayYear
Date
Times & frequency*
REASON*
I give permission for the administration of the medication, according to the instructions listed, to the child listed above.
Date of authorization*

MonthDayYear
Date
Signature (parent/guardian)*
POSSIBLE SIDE EFFECTS TO WATCH FOR WITH THIS MEDICATION:
*REMINDER: For allergies we are required to have an allergy action plan on file for your student. Please have your pediatrician email (kvidal@sapctucson.org) or fax (520-797-6505) one to the office.
Should be Empty: