Shalom School-Based Clinic Consent to Administer a Medication
PARENT/GUARDIAN SECTION
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Medication Name and Dosage
*
Instructions, including time to give medication
*
Med Type
*
Over the counter
Prescription
Controlled
For late/delayed arrival, please
*
Give medication when arrives to clinic
Contact me before giving medication
Hold medication if arrives after _________
*
Write Initials here
For early/alternate arrival, please...
*
Hold the medication
Contact me before giving medication
Give medication at _________
*
Write Initials here
I authorize clinic staff to administer the medication as described here. Medication(s) be stored in secure location in clinic
*
Write Initials here
My authorization will be in effect until a termination or change in medication is submitted in writing or at the end of the school year
*
Write Initials here
I understand all medications will be counted in with SBC staff and parent/adult dropping off medication or an adult school staff witness.All medications must be labeled. Prescription medications must have a valid pharmacy label. Medication(s) may only be labeled for one student
*
Write Initials here
Any medication left in the clinic past the last day of school will be wasted/destroyed per Indiana state law.
*
Write Initials here
I agree it is my responsibility to notify clinic staff of any changes immediately and in writing. This may be done electronically through my child’s patient portal
*
Write Initials here
Please notify me when my child has ____ doses left of their medication to allow adequate time to get a refill.
*
Number of doses left of medication
Please do this by
*
Text
Email
Call
*
Write Initials here
Signature
*
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Name
Daytime #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to student
*
Email
*
example@example.com
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