WESTERVILLE SCHOOLS PRESCRIPTION MEDICATION AUTHORIZATION FORM

Student's Name

First NameLast Name
Date of Birth

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

MonthDayYear
Date
Ending Date of Admin Medication #1

MonthDayYear
Date
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
Date
Ending Date of Admin Medication #2

MonthDayYear
Date
Possible Side Effects Medication #2
Special Instructions Medication #2
Reason for giving Medication #2
Physician/Provider Name
Phone Number
Fax Number
DRR Phone Number
DRR fax Number
Jenna Phone Number
Jenna fax Number
Date of physician signature

MonthDayYear
Date
Physician Street Address Placeholder
Physician City, State, ZIP Placeholder
Should be Empty: