BUCKEYE VALLEY LOCAL PRESCRIPTION MEDICATION AUTHORIZATION FORM

Student's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Medication #1
Circumstance for use
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
Require refrigeration?
Reason for giving Medication #1
Controlled Substance?

YesNo
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
Jenna Phone Number
DRR NPI Number
Jenna NPI Number
Date of physician signature

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