DUBLIN SCHOOLS PRESCRIPTION MEDICATION AUTHORIZATION FORM

Student's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medication #1
Medication #1 Dosage
Route of Admin Medication #1
Time of Admin Medication #1
Beginning Date of Admin Medication #1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Ending Date of Admin Medication #1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Possible Side Effects Medication #1
Reason for giving Medication #1
Special Instructions Medication #1
Medication #2
Medication #2 Dosage
Route of Admin Medication #2
Time of Admin Medication #2
Beginning Date of Admin Medication #2

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Ending Date of Admin Medication #2

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Possible Side Effects Medication #2
Special Instructions Medication #2
Reason for giving Medication #2
Physician/Provider Name
Date of physician signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Physician Street Address Placeholder
Physician City, State, ZIP Placeholder
DRR Phone
DRR Fax
Jenna Phone
Jenna Fax
Phone Number
Fax Number
Should be Empty: