Anna-Jonesboro Community High School
SIU Family and Community Medicine Anna Jonesboro
School Health Center
“Over-The-Counter” Medication Dispensation Authorization Form
Child’s Name: ______________________________
Date of birth: ______________Grade: __________
Parent/Guardian: ___________________________
Best phone #: ______________________________
Below is a list of over-the-counter medications (and/or their generic equivalent) used by the SIU Family and Community Medicine Anna Jonesboro School Health Center nursing service:
Tylenol: headache, menstrual cramps or musculoskeletal pain (if can’t take ibuprofen)
Motrin: headache (if no head trauma), menstrual cramps, musculoskeletal pain, tooth pain
Midol- menstrual cramps
Benadryl: allergic reaction, allergies, itching
Zyrtec: allergic reaction, allergies, itching
Tums/Pepto Bismol: nausea, abdominal cramping, heart burn, (we ensure no fever before giving)
Immodium/Gas X- diarrhea without fever, gas or bloating
Cepacol lozenges: sore throat
Cough drops/ Robitussin cough syrup: cough
Sudafed: congestion, common cold symptoms
Eye Drops- Dry, irritated, itching eyes (not pink eye)
Solarcaine/ Burn spray- minor burns, sunburns
Carmex- Dry cracked lips
Icy Hot- muscle pain
Calaclear/ Calamine- Poison Ivy
Glucose tablets: low blood sugar of known diabetic
Hydrocortisone cream: applied to certain rashes that itch or bug bites
Triple Antibiotic ointment: cuts, dressing wounds
Contact solution: contact issues
Normal saline: clean wounds
Rubbing alcohol: clean piercings
Orajel: tooth pain
Hydrogen peroxide: clean dirty wounds
By signing below (please initial EACH):
_____ I request and consent to the dispensation of the previously listed medications (generics used for cost savings) for the previously listed reasons.
Please check mark one:
o Give as needed.
o Do not give.
_____ I hereby release and hold harmless the SIU Family and Community Medicine Anna Jonesboro School Health Center, SIU Family Medicine, SIU School of Medicine, SIU HealthCare and AJCHS from any and all liability for acting in conformance with this authorization and consent and in a manner consistent with the reasonable standards of care in the community under these circumstances. Parent/Guardian/Child has the right to refuse services.
_____ I understand these services will be documented in the student school health record.
_____ I understand this consent applies to the child’s entire high school career. I can make changes in writing or by completing a new form.
Please sign below:
__________________________________________
Parent/Guardian signature
Date: ____________________
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