NORTH UNION SCHOOLS PRESCRIPTION MEDICATION AUTHORIZATION FORM

Student's Name

First NameLast Name
Medication #1
(Medication write-in)
Medication #1 Dosage
(Dosage write-in)
(Strength/concentration)
(Other instructions)
Time of Admin Medication #1
Ending Date of Admin Medication #1

MonthDayYear
Date
Possible Side Effects Medication #1
Special Instructions Medication #1
Reason for giving Medication #1
Physician/Provider Name
Phone Number
Fax Number
DRR Phone Number
Jenna Phone Number
DRR Fax Number
Jenna Fax Number
Date of physician signature

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