BEXLEY PRESCRIPTION MEDICATION AUTHORIZATION FORM

Student's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Medication #1
Medication #2
Medication #1 Dosage
Medication #2 Dosage
Route of Admin Medication #1
Route of Admin Medication #2
Time of Admin Medication #1
Time of Admin Medication #2
Beginning Date of Admin Medication #1

MonthDayYear
Date
Ending Date of Admin Medication #1

MonthDayYear
Date
Beginning Date of Admin Medication #2

MonthDayYear
Date
Ending Date of Admin Medication #2

MonthDayYear
Date
Possible Side Effects Medication #1
Possible Side Effects Medication #2
Reason for giving Medication #1
Reason for giving Medication #2
Physician Phone Number
Date

MonthDayYear
Date
Should be Empty: