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Authorization For Medications To Be Taken At School
I give school personnel permission to administer this medication per the following instructions:
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* Indicates required question
Email
*
Your email
Name of Student
*
Your answer
Student Date of Birth
*
MM
/
DD
/
YYYY
Name of Medication (one medication per form)
*
Your answer
Dose (Strength/how much)
Your answer
Scheduled times
*
Once a day (7:30 AM)
Once a day (8:30 PM)
Twice a day (7:30 AM/8:30 PM)
Three times a day (7:30 AM, 3 PM, 8:30 PM)
Four times a day (7:30 AM, 11:30 AM, 3 PM, 8:30 PM)
As Needed
Other:
If medication is 'as needed' - How often?
Every 2 hours
Every 4 hours
Every 6 hours
Every 8 hours
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Route (How taken)
*
Mouth
Eye
Ear
Nose
Skin
Other:
Required
What is the medication for? (example: toothache)
*
Your answer
Any special instructions?
Your answer
Possible side effects and actions to be taken?
Your answer
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