|Written by Angela Brown|
|Friday, 28 January 2011 12:45|
PRESCRIBED MEDICATION AUTHORIZATION FORM
TO BE COMPLETED BY PHYSICIAN
I certify that, in my opinion, it is medically necessary that the medication described below be administered to _____________________________ during school hours and that this medication be administered by school personnel.
Reason for medication: ___________________________________________________
Name of medication: ______________________________________________________
Dosage and Time: ________________________________________________________
Symptoms for repeating medication: ______________________________________
Date of prescription: ______________________________________________________
Date: ___________ Name of Physician: ______________________________________
Physician Telephone Number: ______________________________________________
Signature of Physician: __________________________________________________
Note: Please return this form with medication or have your physician mail or fax it back to 812-384-2405. Attention: School Nurse.
OVER- THE- COUNTER MEDICATION REQUEST
Name of Medication:_______________________________________________________
Reason(s) medication is to be given: ______________________________________
Dosage and time to be given at school: ____________________________________
I, ___________________________________, the parent/legal custodian of _____________________________________, request that the school nurse or principal’s designees administer the above medication to ___________________________________ during school hours and at the times indicated. I agree to furnish said medication in the original unopened container with label intact. I understand and accept that Bloomfield School District School Board, its employees, designees are not responsible for any effects of the medication administered.
|Last Updated on Monday, 20 August 2012 12:48|