To be completed by parent or guardian:

I request that my child ________________________________________, grade _____________, receive this medication as prescribed below by our licensed health care provider. This medication is to be furnished by me in a properly labeled container that originates from the pharmacy. I understand that the school nurse or other assigned person will administer this medication. 

Parent or Guardian signature : ________________________________________ Date: _____________

Address: ____________________________________________________________________________

Phone (H): ________________________________  Phone (w): ________________________________ 

To be completed by the licensed health care provider:

I request that my patient, ____________________________________________  DOB: ____________

Diagnosis: __________________________________________________________________________

Name of Medication: __________________________________________________________________

Prescribed Dosage, Frequency, and Route of Administration: _________________________________

___________________________________________________________________________________

Time to be taken during school hours: ______________________ Duration of treatment: ___________

Possible side effect and adverse reactions (if any): __________________________________________

____________________________________________________________________________________

Other Recommendations: _______________________________________________________________

Name of Licensed Prescriber & Title (please print): __________________________________________

Prescriber's signature: _______________________________________________ Date: _____________

Address: __________________________________________________________  Phone: ____________

Nurse's Fax number - 845-351-3402