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Student Medication Information and Consent Form
I have read and understand the medication policies as indicated
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Prescription Medication(s)
A written prescription order form from the prescribing physican must accompany this form. The label affixed to the medication bottle/package will meet the requirement for the pysician's written order.
Over-The-Counter Medication(s)
OTC Medication must be in the original container with the brand label affixed.
REMINDER: PRESCRIPTION AND OVER-THE-COUNTER MEDICATIONS MUST BE KEPT IN THE ORIGINAL CONTAINER WITH THE PHARMACY OR BRAND LABEL AFFIXED. MEDICATIONS WILL ONLY BE GIVEN AS EITHER PRESCRIBED BY THE PRACTITIONER OR THE FDA INSTRUCTIONS THAT ARE FOUND ON THE OTC MEDICATION LABEL
NO MODIFICATIONS OF DOSAGE OR FREQUENCY WITHOUT THE WRITTEN CONSENT BY THE CHILD'S HEALTHCARE PROVIDER
Please administer the prescription medication prescribed below by my child's healthcare provider or Over-The-Counter medication with the FDA instruction found on the OTC medication label
Student's Name
Your answer
MedicatIon Name
Your answer
Dosage (mg & # of tabs)
Your answer
Time to be given
Your answer
Date Medication to be Given/Discontinued. (Medication may be given/kept for one week). Please provide the beginning and end dates for the one week period (ex. 8/10/20 through 8/14/20)
Your answer
Reason For Medication
Your answer
Precautions/Side Effects
Your answer
Parent/Guardian 1 (Name & HOME Phone #)
Your answer
I understand that this electronic signature below provides the same legal standing as a handwritten signature
Parent/Legal Guardian's Signature
Please enter Date Signed
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DD
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YYYY
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