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Prescribed Medicine PDF Print E-mail
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.

Student: __________________________________DOB:_________________________

Reason for medication: ___________________________________________________

Name of medication: ______________________________________________________

Dosage and Time: ________________________________________________________

Symptoms for repeating medication: ______________________________________

Duration: ________________________________________________________________

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 812-381-9715.  Attention: School Nurse.

OVER- THE- COUNTER MEDICATION REQUEST

 

Student: ____________________________________DOB:_________________________

Name of Medication:_______________________________________________________

Reason(s) medication is to be given: ______________________________________

Dosage and time to be given at school: ____________________________________

Duration: ________________________________________________________________

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. 

______________________________    __________________________________
                   Date   Signature of Parent/Legal Custodian

 

Last Updated on Wednesday, 20 August 2014 09:14