Name of Student_______________________________ Date of Birth______________

Address ______________________________________ Grade ___________________

Name of Licensed Prescriber __________________________ Title _______________

Business Telephone Number___________________________

Emergency Telephone Number_________________________

Medication______________________________________________________________

Route of Administration ___________________ Frequency______________________

Dose ___________________________Time to be Administered___________________

(Please note: Whenever possible, medications should be scheduled at times other than school hours)

Specific directions or information for administration: __________________________

_______________________________________________________________________

Date of order: ___________________ Discontinuation Date: _____________________

Diagnosis*: _______________________________________________________________

Any other medical conditions *: ____________________________________________

Optional Information:

Special side effects, contraindications, or possible adverse reactions to be observed:____________________________________________________________

 

Other medications being taken by the student: ___________________________

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(*If not confidential)


Signature of Licensed Prescriber_______________________________