PLEASE READ
All medication releases require a current well care visit. If patient is over the age of 3, a well care visit within the last 12 months. If patient is less than 3, a well care visit per AAP guidelines. Medically approved over the counter medicines will be approved per directions and age on label. Approved medications include:
Form Completion Information
Please complete the information below indicating your contact information, relationship to patient, how you would like to receive your form and you preferred method of delivery.
Person Requesting Form Name:
*
First Name
Last Name
Relationship To Patient
*
Contact Phone
*
Please enter a valid phone number.
Contact Email
*
example@example.com
Please Select When You Would Like Your Form Returned
*
Please Select
RUSH End Of Next Business Day ($40 Fee)
7-10 Business Day ($10-$20 Fee)
How Would You Like To Receive Your Form?
*
Please Select
Pick-Up East Elizabeth Office Only
Deliver Electronically To Email
Parent Completes
Student Name
*
Student ID#
Date of Birth
*
/
Month
/
Day
Year
Date
Grade
School Year
School Student Attends
Fax Number
School/Activity where Medicine is to be Administered
Health Care Provider Authorization and Directions
Name of Medicine
*
The Medicine is
Prescription
Nonprescription
Purpose of Medicine
Dosage
Route Of Administration
Time(s) the Medicine is to be Administered
Starting Date
-
Month
-
Day
Year
Date
Ending Date
-
Month
-
Day
Year
Date
Possible Side Effects Of Medication
Provider
Printed Name Of Health Care Provider
Office Phone
Please enter a valid phone number.
Parent/Guardian Request, Permission and Release
Signature of Parent/Guardian
Clear
Date
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: