Medication Dispensing Authorization Form
Name of Student or Client
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First Name
Last Name
Name of Medication or Supplement (if you have multiple medications or supplements, you must complete a new form for each)
*
Reason medication or supplement is given
*
Dose and time to be given (start and stop date for short term dispensing)
*
I understand that OASN will NOT dispense any prescribed medication without the original bottle. I will ask the pharmacy for an additional bottle for use at OASN. Additionally, medication, supplements, etc. CANNOT be put into lunches, backpacks, etc.
I understand this.
Name of Licensed Physician, PA or ARPN Prescribing (write NA for over the counter or supplements ONLY)
*
Phone Number of prescribing person above
*
Parent/Guardian Signing this form
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I hereby authorize theadministration of medication described above to my child by designated OASN Staff. I hereby indemnify any and allliability of OASN (including it's subsidiary company, Ocala Preparatory Academy), it’s board of directors, staff, Heritage Management Company, and other entities in the treatment of my child. It is understood by theundersigned that personnel will not be responsible for possible side effectsfrom the administration of the above medication and may contact the physicianif there are any concerns about the medication.
*
Submit
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