Medication Authorization Form

Medication Authorization Form for Prescription and Non-Prescription Medications
Section A must be completed by the parent/guardian for ALL medication authorizations. Section A and Section B (must be completed by a physician) must be completed for medication authorizations lasting longer than 10 working days.
Section A

To be completed by parent/guardian
Email*
example@example.com
Medication Authorization for:
Child*

First NameLast Name
Mountain Laurel Montessori School has my permission to administer the following medication:
Medication Name (include brand name)*
Name must be EXACTLY as it appears on the bottle/RX label
Dose*
Dose must be EXACTLY as it appears on the bottle/RX label
How should the medication be administered?*
Example: orally, topically, inhalation, injection, etc.
Time to be administered*
Is this to be taken as needed/PRN medication?*

YesNo
Medication taken as needed shall be administered when the following symptoms are observed:*
Special instructions (if any)
Example: take with food, keep refrigerated, etc.
Expiration date on the bottle/box*
Medication may not be expired
This authorization is effective from:
Start date*

MonthDayYear
Date
End date*

MonthDayYear
Date
Parent/Guardian signature*

Clear
Date*

MonthDayYear
Date
Once you click "Submit," you will be directed to a page that will allow you to download and print the full form. If the medication is to be administered for more than 10 days, you must PRINT the form and bring it to your child's physician to complete Section B. Then return the form to us with the medication in its original container with the original box.
Section B

Must be completed by child's physician
I, ______________________________________(Name of physician)

First NameLast Name
certify that it is medically necessary for the medication(s) listed below to be administered to:
Child's name

First NameLast Name
for a duration that exceeds 10 working days.
Medication name
Dose
Times to be administered
Special instructions (if any)
This authorization is effective from:
Start date

MonthDayYear
Date
End date

MonthDayYear
Date
Physician's signature
Date

MonthDayYear
Date
Physician's Phone
Section A is now complete. Click Submit below.
Should be Empty:

Medication Authorization Form for Prescription and Non-Prescription Medications

Section A