CANAL WINCHESTER SCHOOLS PRESCRIPTION MEDICATION AUTHORIZATION FORM

School year
Student's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Medication #1
(Medication write-in)
Medication #1 Dosage
(Dosage write-in)
(Strength/concentration)
Route
Time of Admin Medication #1
Starting Date of Admin Medication #1

MonthDayYear
Date
Ending Date of Admin Medication #1

MonthDayYear
Date
Possible Side Effects Medication #1
Special Instructions Medication #1
Physician/Provider Name
Phone Number
Fax Number
DRR Phone Number
Jenna Phone Number
DRR Fax Number
Jenna Fax Number
Physician Street Address Placeholder
Physician City, State, ZIP Placeholder
Not Applicable "X"
Should be Empty: