MEDICATION PERMISSION REQUEST FORM
MEDICATION PERMISSION REQUEST FORMFor Prescription and OTC MedicationsIn accordance with New York State Education Department regulations, all students who need medication during school hours must do the following: Present a written consent form signed by the parent or legal guardian. Bring the medication in the original prescription bottle, properly labeled by a registered pharmacist as prescribed by law. Present a completed medication permission request form from the prescribing physician as follows: NAME OF STUDENT: __________________________________________ Date of Birth:_________ To be Completed by Physician MEDICATIONDOSAGETIME AT SCHOOLRelated Diagnosis:_____________________________________________________________________Additional Comments:__________________________________________________________________The following side effects are common: ____________________________________________________ _________________________________________ _______________ Physician’s Signature Date_____________________________________ ________________________ Physician’s Name Printed Physician’s TelephoneTo be Completed By ParentI, _________________________________________, give permission for my child to receive the above medication(s) as directed. ________________ _____________________________________ ______________________ Date Parent’s / Guardian’s Signature Telephone ................
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