QUEEN OF PEACE SCHOOL

 PHYSICAN’S AUTHORIZATION FOR ADMINISTRATION

OF MEDICATION BY SCHOOL PERSONNEL

 

NAME OF STUDENT                                                                                                                                                                 

NAME OF MEDICATION                                                                                                                                                         

DOSAGE                                                                                                                                                                                         

INSTRUCTIONS FOR ADMINISTRATION (ROUTE, TIME, HOW OFTEN?)                                                                             

                                                                                                                                                                                                        

                                                                                                                                                                                                        

SPECIAL STORAGE INSTRUCTIONS                                                                                                                                           

                                                                                                                                                                                                        

POSSIBLE SIDE EFFECTS                                                                                                                                                               

                                                                                                                                                                                                        

DESCRIPTION OF POSSIBLE REACTION THAT, IF OBSERVED, SHOULD BE REPORTED TO PHYSICIAN 

                                                                                                                                                                                                       

                                                                                                                                                                                                       

EXPIRATION DATE OF THIS REQUEST                                                                                                                                   

DATE                                                               PHYSICIAN’S SIGNATURE                                                                                 

                                                                           PHYSICIAN’S NAME                                                                                         

                                                                           PHYSICIAN’S ADDRESS                                                                                    

                                                                 PHYSICIAN’S TELEPHONE NUMBER                                                                       

 

PARENT AUTHORIZATION FOR ADMINISTRATION

OF MEDICATIONS BY SCHOOL PERSONNEL

 

I                                                                                                                                    AUTHORIZE SCHOOL PERSONNEL TO

                                                  (Parent or guardian)

ADMINISTER                                                                                                                                         AS  INSTRUCTED  BY

                                                                (Name of medication)

 

                                                                                                                                               AND AGREE TO; 1) DELIVER THE

                                (Name of physician)

 MEDICATION TO SCHOOL; 2) TO NOTIFY THE SCHOOL IF I CHANGE PHYSICIANS; 3) TO NOTIFY THE 

SCHOOL IF THE MEDICATION OR DOSAGE IS CHANGED OR DISCONTINUED.

 

                                                                                PARENT SIGNATURE                                                                                    

                                                               DATE