Authorization to Dispense Prescription Medication

Authorization to Dispense Prescription Medication

This form MUST be completed, even if your student does not take medication during school hours.
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Option 1: No prescription medication during school hours
My child does not take medication during school hours.
Parent/Guardian Signature

Clear
Parent/Guardian Name

First NameLast Name
Date

MonthDayYear
Date
Only complete below this section if your student will be taking medication at school.
Option 2: Administering of prescription medication during school hours

A physician must complete Medication Administration form (below) in order for Brookhaven Treatment and Learning Center Staff to administer prescription medication to students.
I request that my above identified child receive the medication listed below as prescribed by the below identified doctor. This medicine is being delivered or sent in its original pharmacy bottle with childproof top in place. I understand that Brookhaven Treatment & Learning Center will dispense the medication below as directed by the prescribing physician.
Parent/Guardian Signature

Clear
Parent/Guardian Name

First NameLast Name
Date

MonthDayYear
Date
Physician Information
Physician Name

First NameLast Name
Physician's Location of Practice
Physician Phone Number

Area CodePhone Number
Medication to be administered during school hours
Medication
Dosage of medication to be administered during school hours
Medication dosage
Time for medication to be administered

:HourMinutesAM/PM Option
Physician's Medication Administration Information

to be completed by prescribing physician only
Child Name

First NameLast Name
Child Date of Birth

MonthDayYear
Date
Name of Medication
Method of dispensing
Time to be taken
Possible side effects and/or adverse reactions/contraindications
Other comments/recommendations
Name of Prescribing Physician

First NameLast Name
Signature of Prescribing Physician

Clear
Date

MonthDayYear
Date
Should be Empty:

Authorization to Dispense Prescription Medication

Option 1: No prescription medication during school hours

Option 2: Administering of prescription medication during school hours

Physician Information

Physician's Medication Administration Information